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SYSTEM 
 
 O F 
 
 SURGERY. 
 
 B Y 
 
 BENJAMIN BELL, 
 
 MEMBER OF THE ROYAL COLLEGES OF SURGEONS 
 
 OF IRELAND AND EDINBURGH, 
 
 . NE OF THE SURGEONS TO THE ROYAL INFIRMARVj 
 
 A.VD FELLOW OF THE ROYAL SOCIETV OF EEIN'BURGH. 
 
 ILLUSTRATED WITH COPPERPLATES, 
 
 VOLUME I, 
 The third EDITION Corrects 
 
 EDINBURGH: 
 
 Printed for CHARLES ELLIOT, Edinburgh 
 
 C. ELLIOT AND Co. N° 332, oppofite Somerfet- 
 
 Buildings, Strand, London ; 
 
 AND G. G. J. & J. ROBINSON, London. 
 
 M,DCC, J. XXXVII. 
 
 .Mj^TiHMii 
 
iv DEDICATION. 
 
 debted to you in a particular man- 
 ner^ for any anatomical knowledge 
 of which i am polTeiTed. I have 
 therefore to defire, that you will 
 accept of this public teftimony of 
 my gratitude ; and, if this firfl Vo- 
 lume of a Syflem of Surgery merits 
 any fliare of your approbation, may 
 I requeft, as aa additional obliga- 
 tion, the favour of that protection, 
 which your countenance will be fure 
 to afford it? I remain, very re- 
 fpectfully, 
 
 
 
 S 
 
 I R, 
 
 
 Ypur 
 
 obedi 
 
 ient 
 
 humble fervant, 
 
 
 
 
 Benjamin 
 
 Bell. 
 
 liDIN. Nov.? 
 
 
 
 
 
P R E F A C E. 
 
 SOME years ago I publifhed a Volume of 
 Obfervations on different parts of Surgery; 
 and the indulgent reception with which it was 
 favoured, has encouraged me to lay another vo- 
 lume before the public : This, as well as the 
 former, is intended as part of a work, which, 
 when completed, will form a general Syftem of 
 Modern Surgery. 
 
 In announcing an undertaking fo arduous and 
 fb extenlive, it may be proper to explain the 
 reafons which induced me to enter upon it, and 
 to point out the plan upon which I intend to pro- 
 ceed. 
 
 The learned and judicious Heiiler publifhed 
 the lafl edition of his Syflem of Surgery fo long 
 ago as the year 1739. In this work, the author 
 comprehends whatever the experience of former 
 times had approved as ufeful ; and adds fuch ob- 
 fervations as his own knowledge in Anatomy and 
 praftice in Surgery fuggefted. 
 
 This was the firfl, and it ftill remains the on- 
 ly, complete Syflem of Surgery of which we are 
 poiTefTed. 
 
 A3 Since 
 
VI 
 
 P R E F A C £. 
 
 Since this publication of Heifter's, many va- 
 luable difcoveries and important improvements 
 have been introduced ; and the Public has at 
 different times been favoured with accounts of 
 them by their refpedive authors. But thefe pub- 
 lications treat of various fubjedls, and are all ne- 
 ceffarily unconneded with each other ; fo that 
 the additional knowledge with which our art has 
 been of late enriched, lies in a very diffufed, and 
 to many perhaps in an inacceffible, lituation. 
 
 It is true, that fome attempts have been made 
 towards a full fyftematic arrangement of chirur- 
 gical fubjefts. Platner publilhed his Inftitutes 
 of Surgery in the year 1745 ; and Ludwig fa- 
 voured the world with a limilar publication in 
 1767. But both thefe works may be properly 
 confidered as heads of ledures which were read 
 by thofe celebrated profeflbrs at Leiplic ; and al- 
 though pofTeffed of much merit, they are too 
 concife to give a clear and diltind; idea of the 
 various topics of which they treat. 
 
 In confequence of this, the young Undent in 
 the art, as well as the intelligent practitioner 
 Avho is defirous of information, is obliged to con- 
 fult a great variety of publications, which he fre- 
 quently finds much difficulty in procuring, and 
 which his other occupations will not always al- 
 low him fafficient time to perufe. 
 
 Induced 
 
PREFACE. vii 
 
 Induced by thefe conliderations, and having 
 frequently experienced much inconvenience 
 from the want of a well-digefted Syftem of 
 Surgery, I have been led to attempt the prefent 
 work : Which, though it may not afford much 
 new information to praftitioners of experience 
 and refle6lion, who are accullomed to perufp every 
 publication that appears ; yet to the younger part 
 of the profellion, and to all thofe whofe oppor- 
 tunities of acquiring knowledge have not been 
 conliderable, I flatter myfelf it may prove fervice- 
 able. 
 
 My defign is, to exhibit a view of the art of 
 Surgery, as it is at prefent pradifed by the molt 
 expert furgeons in Europe, as far at leall as my 
 own obfervation in the courfe of attending diffe- 
 rent Hofpitals, joined to the advantages of reading 
 and correfpondence, have enabled me to do fo. 
 
 It may be proper to remark, that a number of 
 improvements fuggefted at different times in va^ 
 rious parts of Surgery, are here purpofely omit- 
 ted. Within thefe laft thirty or forty years, fuch 
 a rage has prevailed for the invention of new in- 
 ftruments, that it has become fafhionable to ac- 
 company every publication with fomething nev/ 
 and lingular of this kind. Some of thefe have 
 undoubtedly been productive of much advan- 
 tage : . But the greateft part of them tend more 
 A 4 t# 
 
viii PREFACE. 
 
 to evince the ingenuity of their authors, than to 
 render the operations for which they were in- 
 tended, more cifily accomplilhed ; for, althougli 
 facility in performance is one great obj eel in every 
 furgical operation, yet the ends we have in view 
 are in general attained by very iimple means. 
 
 Indeed, one objedt of the prefent publication, 
 is, an endeavour to diveft the art of all that ufe- 
 lefs machinery with which it has been encum- 
 bered ; and to retain only what appears evident- 
 ly to reft upon the folid balis of experience. I 
 have therefore been particularly attentive, in ad- 
 mitting nothing which I have not myfelf found 
 confirmed by trial, or which I have not known 
 to prove ufeful in the hands of others. 
 
 My connexion with a large hofpital, the Roy- 
 al Infirmary of Edinburgh, to which the greateft 
 part of the poor in Scotland requiring the aflift- 
 ance of chirurgical operations, areaccuftomed to 
 refort, together with that private pradice which 
 has fallen to my fliare, have given me opportu- 
 nities both of repeatedly performing every opera- 
 tion myfelf, and of being frequently prefent when 
 they were performed by fome of the moft expert 
 furgeons of this place; a circumftance which en- 
 ables me to fpeak with fome degree of confidence, 
 though, I hope with due caution, of e'ach. With- 
 out fuch advantages, I fnould not have thought 
 
 my- 
 
PREFACE. is; 
 
 xiiyfelf juftifiable in undertaking the prefent 
 Work ; for it is chiefly by hofpital practice that 
 any individual can acquire fuch experience in 
 the great variety of chirurgical operations, as to 
 be able to form any accurate ideas concerning 
 them. 
 
 It is not propofed in the courfe of the follow- 
 ing Work, to attempt a particular fyitematic ar- 
 rangement of the fubje6ls of which it treats. Ar- 
 rangements of this kind have indeed been em- 
 ployed with advantage in different branches of 
 fcience : The ftudy of natural hiltory has been 
 much facilitated by their means; andaknowledge 
 of the more general difeafes to which the human 
 body is liable, is perhaps acquired with more eafe 
 by the comprehenlive views which a well digeft- 
 ed nofological fyftem gives of them. But, as 
 diforders of every kind requiring the affiftance of 
 the operative part of Surgery, are perfedly local 
 and unconneded with one another by means of 
 fymptoms common to each ; and as it feldom hap- 
 pens, that there is much fimilarity in the means 
 neceffary for the removal of fuch difeafes; the 
 parade of claffification under fuch circumltances, 
 although it may ferve to difplay the fancy of an 
 author, can have no effe6l either in rendering the 
 ftudy of Surgery more eafy, or thepradice of it 
 more attainable. 
 
 Yet 
 
s pre]^ag£:. 
 
 Yet when one fubjecl is naturally connecfted 
 with another, I fhall not any-where attempt to 
 feparate them ; and when the defcription of any 
 operation can be more eafily imderltood from 
 what has been fold concerning another, I Ihall 
 confider them in immediate fuccelHion : But, in 
 other inftances, where no connection can be tra- 
 ced between the different articles treated of, no 
 methodical arrangement can be With advantage 
 attempted. 
 
 Were I to endeavour to trace the fucceffive im- 
 provements which have been made in furgery 
 withinthefe laft fiftv or fixty years, Ilhould often 
 "find it difficult, and.fometimes impcilible, to de- 
 termine by whom the practice, as it is now efta- 
 bliftied, was introduced ; and in order to give a 
 fair account of the progrefs of the different ope- 
 rations of furgery, from their rude to their im- 
 proved Hate, I fhould be under the neceflity of 
 entering into a full chronological hiflory of each. 
 While inquiries of this kind could ferve no ufe- 
 ful purpofe, they would tend to render more pro- 
 lix, a work which, from the variety of its fub- 
 jects, mufl necelTarily extend to a great length. 
 I fiiall therefore in general decline them. On 
 Ibme occafions, however, when the author of any 
 remarkable improvement is loiown with certain- 
 ty, I fliall not fail to give him all the credit which 
 his difcovery feems to merit. 
 
 I Such 
 
? R E ?■ A C E. 
 
 X! 
 
 Such of my readers as are fond of theoretical 
 difquifitions, will, I am afraid, be frequently dif- 
 appointed. When the fubjecl under confidera- 
 tion can be rendered more clear and intelligible 
 by it, I have occafionally employed fuch reafon- 
 ing as experience and common fenfe feem evi- 
 dently to fupport ; but I have every where fludi- 
 oufly guarded againlt entering on the difcuffion 
 of doubtful and fpeculative opinions, 
 
 InconlideringtMfe different fubjects, the appear- 
 ance or fymptoms of thediforder — the ufualcau- 
 fes known to induce it — its probable confequen- 
 ces — and the beft method of treatmeiit-^are par- 
 ticularly defcribed in fucceffion : and when an 
 operation of importance is to take place, the 
 parts which lie contiguous, but which the ope- 
 rator ought to avoid, are pointed out, as well as 
 thofe which he is under a neceffity of dividing. 
 
 In defcribing the different operations, I have 
 uniformly adhered to the method at prefent prac- 
 tifed by the beft furgeons, excepting in fuch in- 
 ftances where improvements of my own are pro- 
 pofed ; and none of thefe are any where recom- 
 mended, the utility of which has not been afcer- 
 tained by repeated trials. 
 
 In a work of this nature, it muft unavoidably 
 happen, that on feveral occalions I differ in opi- 
 nion from various refpeclable authors ; but 
 
 where- 
 
%\i PREFACE. 
 
 wherever I do fo, no other motive, I hope, will 
 appear for it, than a wilh to render more perfed: 
 an art which I am attempting to defcribe and 
 illuftrate. 
 
 I am fully award of the difficulties to be en. 
 countered in carrying on and completing this de- 
 iign ; and am fo diffident of my abilities to do 
 juftice to the undertaking, that, even after acon- 
 liderable part of the materials are prepared, I 
 have chofen this mode of pullliihing it in fepa- 
 rate volumes, that I may thereby have an op- 
 portunity of difcovering the fentiments of the 
 public, with regard to its merit and utility ; a 
 circumftance, by which I will be in a great mea- 
 fure determined in the farther e^f ecution of my 
 plan. 
 
 C O N^ 
 
CONTENTS. 
 
 CHAP. I. 
 
 
 • 
 
 Page 
 
 Sutures, 
 
 17 
 
 SEC T I ON I. 
 
 
 Of Sutures in general^ 
 
 SECTION II. 
 
 17 
 
 Of the interrupted Suture, 
 
 SECTION III. 
 
 19 
 
 Of the filled Suture, 
 
 SECTION IV. 
 
 24 
 
 Of the Glovers Suture, 
 
 SECTION V. 
 
 26 
 
 Of the Twifled Suture, 
 
 27 
 
 CHAP. II. 
 
 0///?^ Ligature o/' Arteries, and othe^ 
 means employed by Art for putting a flop to 
 Hemorrhagies. 
 
 CHAP. III. 
 Q/^Blood-letting - 77 
 
 SECTION I. 
 
 Of Blood-letting in general, - 77 
 
 SECTION 11, 
 Pfa Thrombus or Ecchymojis, • 107 
 
xiv CONTENTS. 
 
 Pago 
 
 SECTION III. 
 
 Of Wounds of the Arteries, - . 1 1 1 
 
 SECTION IV. 
 Of Wounds or Pricks in the Nerves and 
 
 Tendons, - - 119 
 
 SECTION V. 
 Of Bhod-letting in the Arm, ' - 148 
 
 SECTION VI. 
 Of Blood-letting in the Jugular Vein, 154 
 
 SECTION VII. 
 Of Blood-letting in the Ankles and Feet, 157 
 
 SECTION VIII. 
 Of Arteriotomy, - - 160 
 
 SECTION IX. 
 Of Topical Blood-letting, . - 166 
 
 CHAP. IV, 
 
 (y Aneurisms, - 178 
 
 SECTION!. 
 
 General Remarks on Aneurifms, 178 
 
 SECTION II, 
 Of the Treatment of Aneurifms, 226 
 
 CHAP. V. 
 
 (y Hernia, - 254 
 
 SECTION I. 
 
 Of Her nice in general, - .254 
 
C: O N T E N T S. XV 
 
 Page 
 
 SECTION II. 
 
 Of the Bubonocele, - 311 
 
 SECTION III. 
 Of the Hernia Congenita, - 352 
 
 S E C T I O N IV. 
 Of the Crural or Famoral Hernia^ 356 
 
 SECTION V. 
 Of the Exoniphalos, or Umbilical Hernia^ 366 
 
 SECTION VI. 
 Of Ventral Hernia, - 372 
 
 SECTION VII. 
 Of the Hernia of the foramen Ovale, 373 
 
 SECTION VIII. 
 Of the Hernia Cyjlica, or Hernia of the Uri- 
 nary bladder, - 377 
 
 CHAP. VI. 
 
 Of the Hydrocele, - 382 
 
 SECTION I. 
 
 General Remarks on the Hydrocele, 382 
 
 SECTION II. 
 Of the Anafarcous Hydrocele of the Scrotum, 393 
 
 SECTION III. 
 Of the Hydrocele of the Tunica Vaginalis 
 Teflis, - . 406 
 
 SECTION IV. 
 Of the Hydrocele of a Hernial Sac, 461 
 
TLvi CONTENTS, 
 
 Page 
 SECTION V. 
 
 Of the Anajarcous Hydrocele of the Sper- 
 matic Cord, - 469 
 SECTION VI. 
 
 Of the Encyfled Hydrocele of the Spermatic 
 Cord, - - ' 473 
 
 CHAP. VII. 
 
 Of the H-s:matocele, - 485 
 
 CHAP. VIII. 
 
 O/theYA'RICOQELEy CiRSOCELE, SPERMA- 
 TOCELE, ^K<i PNEUMATOCELE, 495 
 
 CHAP. IX. 
 
 Of the Sarcocele, or Scirrhous Tes- 
 
 TICLE9 "• JOI 
 
 CHAP. X. 
 
 Q/*/^^ Diseases o/*//:?^ Penis, - 531 
 
 SECTION I. 
 
 OfthePhy??ioJis, - - 531 
 
 SEC TION II. 
 
 Of the Paraphyviofis, - 539 
 
 SECTION III. 
 
 Of Amputation of the Penis j '^c, 543 
 
 Explanation of the Plates. 551 
 
TREATISE 
 
 ON THE 
 
 THEORY AND PRACTICE 
 
 O F 
 
 U R G E R ^ 
 
 CHAPTER I. 
 
 0/* S U T U R E S. 
 
 SECTION I. 
 
 Of Sutures in genera/, 
 
 AS futures of one kind or another are 
 found neceflary, not only in every 
 large wound, but in almod every opera- 
 tion of importance, the confideration of 
 Vol, L B this 
 
1 8 Of Sutures, Chap. 1* 
 
 this fabjedl feems firfl: to require our at- 
 tention, 
 
 A variety of futures have been pra(5lifed 
 by furgeons, each of which has from long 
 experience been applied to a particular pur- 
 pofe, viz* The interrupted future ; the quill- 
 ed future ; the glover's and the twilled 
 future. Many others are enumerated by 
 ancient writers : but the four now men- 
 tioned are the only fpecies of futures at 
 prefent in ordinary ufej and evenof thefe, 
 fome, we think, might with propriety be 
 omitted. 
 
 The intention of every future, is to unite 
 parts, which either by accident or defign 
 have been divided. Another mode of ef- 
 fecfling this, is through the intervention of 
 adhefive plaflers : and this by furgeons 
 has been termed the falfe or dry future ; 
 in oppolition to the others performed by 
 the needle, which are denominated the 
 true or bloody future. — But as the confi- 
 deration of this fubjec^, namely, the ufe. 
 of adheiive plaflers in wounds, will be 
 more properly introduced in a fubfequent 
 
 part 
 
Sea. II. Of$umres, 19 
 
 part of this work, we {hall not in this place 
 enter upon its difcuflion. 
 
 SECTION n. 
 
 Of the Interrupted Suture, 
 
 YN deep wounds, when a reunion of the 
 divided parts is intended, this is the fu- 
 ture to which we generally have recovirfe j 
 but from what will be afterwards more 
 fully explained when treating of wounds, 
 and from what will prefently farther appear, 
 it does not feem to be fo well adapted to 
 this purpofe as the twifled future. When 
 it is determined, however, to make trial of 
 the interrupted future, the following is the 
 eafieft mode of doing it. 
 
 In every wound where futures are found 
 necelFary for the retention of parts, it has 
 commonly been confidered as good prac* 
 tice, to carry the needle and ligature to the 
 bottom of the fore, fo as to give as little 
 room as poflible for matter colicdling un- 
 derneath J and the ufual mode of elFcdt- 
 ing this, is by introducing the needle fron^ 
 B 2 withoul^ 
 
«o Of Sutures, Cliap. L 
 
 ■withont inwards, and again from the bot- 
 tom of the wound to the fame diftance on 
 the oppofite fide. But this future, it may 
 be remarked, is much more neatly, and at 
 the fame time more eafily performed, by 
 pafling both ends of the thread from with- 
 in outwards ; which is readily done by 
 iifing two needles upon each thread, in- 
 itead of one. A needle being put upon 
 each end of the fame thread, and each 
 needle being inferted at the bottom of the 
 fore, and pullied outwardly fo as to pafs 
 out at a proper diftance from the edge of 
 the wound, the needles are then to be taken 
 off, and the threads allowed to remain till 
 all the ligatures are palTed which the ex- 
 tent of fore feems to require. 
 
 The number of ligatures neceflary for 
 any wound, muft in a great meafure de- 
 ' pend upon the extent of divided parts. By 
 authors in general it has been laid down 
 as an eftablifhed rule, that one future is 
 fully fufficient for every inch of wound. 
 It will frequently indeed happen, that this 
 number is found fufficient^ but in fome in* 
 
 (lances. 
 
Sedl. II. Of Sutures » it 
 
 fiances, particularly where mufcular parts 
 are deeply cut tranfverfely, and where con- 
 f^quently a great degree of retradion oe- 
 Gurs, a greater number of flitches are ne- 
 celTary : Whenever a number of angles, too, 
 occurs in a wound, more ligatures are re- 
 quired than in a ftraight wound of the 
 fame extent ; for, at every angle, however 
 inconfiderable it may be, there ought to be 
 a future. 
 
 In pafling the ligatures, great care is 
 neceffary to pierce the fkin at a fufficient 
 diftance from the td^t of the wound : for 
 if they do not comprehend a thicknefs of 
 parts in fome meafure proportioned to the 
 depth of the wound, and to the extent of 
 retradlion which may be expecfted, they will 
 very readily cut through the parts entirely. 
 - — By fome authors we are diredled to enter 
 the ligatures, at a diftance from the edges 
 of the fore nearly equal to the depth of the 
 wound. This rule, however, will by no 
 means be found to anfwer in pradlicc. 
 Thus, in a very deep wound, for inftance 
 f f about three inches, no neceility can oc- 
 
 ? 3 ^m 
 
lit Of Sutures » Chap. I. 
 
 cur for carrying the ligatures three inches 
 from the edges of the lore ; and again, i^* 
 very fuperficial cues, it fometimes happens 
 that the Hgature ought to be pafled out at 
 a diftance from the edges of the wound 
 greater than its depth. It ought not, in 
 almoft any cafe, to be lefs than half an 
 inch from the edge of the fore; and it will 
 feldom happen, even in the largefl wounds, 
 that an inch is not found to be a fufficient '^-^^ 
 diftance. 
 
 It will be readily underftood, that the 
 {Irerigth of the ligature and fize of the 
 needle ought always to be proportioned to 
 the depth of the fore and retrad^ion of 
 parts. The feveral fizes of needles repre- 
 fcnted in Plate I. are fuch as have been 
 found necelTary in pra^flice ; and the li- 
 gatures to be ufed along with them ought 
 to be fuch as nearly, though not entirely, 
 to fill the eyes of the different needles. 
 in order to make the ligatures pafs more 
 eafily, to render them more durable, and 
 at the fame time to make them more 
 lufceptible of a flattened form, which 
 
 does 
 
flate I. 
 
 ^> ^• 
 
 \y>'a. o: 
 
 ,yi. 
 
 '/•/ 
 
 s/./w/f ':y^A 
 
S€<51. II. Of Sutures, 2 
 
 J 
 
 does not fo readily cut through the c on 
 tained parts as a round one, they ought 
 all to be well covered with fine bees- 
 wax. 
 
 As foon as the threads are all pafTed, the 
 lips of the wound ought to be preffed to- 
 gether and fupported by anaffiftant till all 
 the ligatures are firmly tied ; beginning 
 either in the middle of the wound, or at 
 one end, as the operator inclines. In ty- 
 ing the knots, it is ufual to pafs the ends 
 of the threads twice through the firft noofe, 
 in order to prevent their yielding ; and 
 when this is done, it is alleged by feme 
 that there is no neceffity for more than 
 one knot upon each ligature ; but as two 
 knots are very eafily made, and as every 
 chance of their yielding is thereby effec- 
 tually prevented, this precaution ought 
 never to be omitted. It is a pracflice with 
 fome furgeons to infert a piece of lint be- 
 tween the firft and fecond knots, or be- 
 tween the firft knot and the fkin below, iii^ 
 order to favethe parts underneath from the 
 l^refTure of the knots ; but as in reality all 
 B 4 Aich 
 
$4 Of Sutures » Chap. I, 
 
 fuch means of protedion afFord no advan- 
 tage of importance, and as they prevent the 
 knots from being made with exattnefs, they 
 ought therefore to be laid entirely alide. 
 
 By fome v^^riters on this fubjedl, we are 
 delired not to bring the knots of ligatures 
 immediately upon the edges of the wound, 
 but rather to carry them to one fide, over 
 upon the found teguments : but whoever 
 'has tried both methods, will at once be fen- 
 fible, that this is by no means an improve- 
 ment ; for in no way can both fides of the 
 fore be equally fupported, but by the knots 
 being pafTcd immediately above the lips of 
 the divided parts, 
 
 SECTION III. 
 
 Of the filled Suture, 
 
 A S the quilled future is Hill employed by 
 fome pra(5litioners, it is here thought 
 ncceffary to defcribe the mode of perform- 
 ing ic. 
 
 In deep wounds attended with much re- 
 traction, it is always a neceiTary precau- 
 tion. 
 
Seifl.in. Of Sutures] ij- 
 
 tion, to afTift the operation of the liga-^ 
 tures, by means of bandages fo applied as 
 to afford as much fupport as pofTible to the 
 divided parts ; But, even with every affift- 
 ance of this nature, it now and then hap- 
 pens, that the divided parts cannot be kept 
 together, retradlion occurs to a greater or 
 leiTer degree, and the ligatures of courfe 
 cut afTunder the foft parts they v/ere at firll 
 made to furround. 
 
 With a view to prevent this receding of 
 the teguments and other parts, it was long 
 ago propofed to add to the interrupted fu- 
 ture what was fuppofed would afford an 
 additional fupport; viz. quills, or pieces of 
 plafler rolled up into the form of quills; 
 one of which being placed on each fide of 
 the wound, the doubling of the ligature is 
 made to include the one, and the knot to 
 prefs dire(5lly upon the other, inRead of 
 being made immediately on the edges of 
 the fore as was directed for interrupted 
 futures. 
 
 It is at once evident, however, that the 
 ligatures mult here make the fame degree 
 
 of 
 
%S Of Sutures, Chap. L 
 
 of prefTure on the parts through which 
 they pafs, as they do in the interrupted 
 future; and this being the cafe, it is equal- 
 ly obvious, that the interpofition of thefe 
 fubftances cannot be of any ufe. This fu- 
 ture is accordingly now very rarely prac- 
 tifed, and it is probable that it will be foon 
 laid entirely afide. 
 
 SECTION IV. 
 
 Of the Glover* s Suture, 
 
 n^HIS future receives its name from be- 
 ing that which the glovers commonly 
 ufe. As it is exceedingly fimple, and very 
 univerfally known, it does not here require 
 a particular defcription : We fhall there* 
 fore juft fhortly obferve, that it confifts 
 in a ferics of flitches all conneded with 
 one another, and continued in an oblique 
 fpiral diredion along the courfe of the 
 divided parts intended to be kept toge- 
 ther. 
 
 This future has hitherto been univer- 
 fally employed for reuniting fuch parts of 
 
 the 
 
Sea.V. Of Sutures: %j 
 
 the inteftmes as have been divided by 
 wounds; but, when treating of accidents 
 <of this kind, I fhall endeavour to fhow, 
 that the fame end may be more perfedly 
 attained, and probably with lefs danger, 
 by means of the interrupted future; fo 
 that as this future has almoft never been 
 applied to any other purpofe, it will like- 
 wife in all probability foon fall into dif» 
 life. 
 
 SECTIONV. 
 
 Of the Twijled Suture, '" ^" 
 
 T>Y the term Twifted Suture is meant, 
 that fpecies of ligature, by which parts, 
 either naturally or artificially Separated, 
 are united together, by means of ftrong 
 threads properly twifted round pins or 
 needles puflied through the edges of the 
 divided parts. 
 
 This future is commonly employed for 
 the purpofe of uniting the parts in cafes of 
 hare-lip; and this indeed is almoft the only 
 \if? to which it has been hitherto applied: 
 
 But 
 
^3 Of Sutures, Qiap. I, 
 
 But we may here remark, that it may with 
 great advantage be put in pradice in a va- 
 riety of other cafes, particularly in all artifi- 
 cial or accidental divifions either of the lips 
 or cheeks; and, in every wound in other 
 parts that does not run deep and in which 
 futures are neceflary, this future is prefer- 
 able to the interrupted or any other. 
 
 In very deep wounds, for inftance in all 
 wounds extending to a greater depth than 
 an inch and a half, the interrupted future 
 is the only one that is admiffible; for, in 
 all fuch deep cuts, the pins neceflary in 
 the twifted future cannot with propriety 
 be employed, as they cannot be introduced 
 to fuch a depth, and afterwards fo twifted 
 with ligatures as to reunite the divided 
 parts, without great pain to the patient. 
 In fuch wounds, therefore, we muft of ne- 
 ceflity have recourfe to the interrupted fu- 
 ture. But it may be here remarked, that 
 wounds of this depth requiring the aid of 
 futures, are very rarely met with: fo that, 
 in by much the greatefl proportion of 
 ■wounds where futures are advifable, the 
 
 twilled 
 
Ssa. V- of Sutures. a^ 
 
 twifted future will be found pradlicable ; 
 and whenever it is fo, it ought certainly 
 to be preferred to every other^ as being 
 obviouily better calculated, even than the 
 interrupted future^ for the retention of di- 
 vided parts. The pins made ufe of for 
 twifling the threads upon, ought to be 
 made of a flat form, fo as not to cut the 
 parts through which they pafs, fo readily 
 as the ligatures employed in the interrupted 
 future: And thus one great obje(5\ion to 
 the latter is very effedlually obviated; for, 
 every pradlitioner muft be fenfible of this 
 being the greateft inconvenience attending 
 the interrupted future, that when mufcular 
 parts are divided, fo as to produce much 
 retracflion, the ligatures employed for re- 
 taining them, ahiiofl conftantly cut them 
 through before a reunion is accomplithed; 
 whereas, the flatnefs of the pins ufed in the 
 twifted future, a id upon which, it may be 
 remarked, the vvrhole prefTure produced by 
 the ligatures is made to reft, proves in ge- 
 neral a very efFedual preventative againft 
 this occurrence. 
 
 The 
 
p 0/ Sutures. Chap. I^ 
 
 The pins ufed in this operation have 
 commonly been made of filver ; and, in 
 order to make them pafs with greater eafe, 
 fleel points have been added to them. As 
 gold pins, however, are capable of recei- 
 ving a fufficient degree of fharpnefs, which 
 renders the intervention of fteel points 
 quite unnecefTary; and as gold is more 
 cleanly than filver, from its not acquiring 
 £o readily that kind of craft which immer- 
 fion in fluids is apt to produce upon the 
 other J pins of this metal are therefore 
 preferable. 
 
 The form and fize of pins reprefented 
 in Plate. II. are what experience has fhown 
 to be the mofl: ufeful for every ordinary 
 purpofej but, for particular ufes, the 
 fize muft no doubt be fubje<5l to varia* 
 tions. 
 
 The manner of performing this opera* 
 tion is as follows : The divided parts in- 
 tended to be reunited, mUft by the hands 
 of an affiftant be brought nearly into con- 
 tact j leaving jufl as much fpace between 
 the edges of the fore, as to allow the fur- 
 3 S^on 
 
Sea.V. Of Sutures. jt 
 
 geoQ to fee that the pins are carried to a 
 proper depth. This being done, one of 
 the pins muft be introduced through both 
 fides of the wound, by entering it on one 
 fide externally, pufhing it forwards and 
 inwards to within a little of the bottom 
 of the wound, and afterwards carrying ie 
 outwardly through the oppofite fide, to 
 the fame diftance from the edge of the 
 fore that it was made to enter at on the 
 other. 
 
 The diftance at which the needle ought 
 to enter from the edge of the fore, muft be 
 determined by the depth of the wound, 
 and by the degree of retradion produced 
 in the divided parts. In general, however, 
 it is a proper rule in deep wounds, to 
 carry the pins to a diftance from the edges 
 of the fore, nearly the fame with the depth 
 to which they penetrate: And it may be 
 alfo remarked, that, whatever the deepnefs 
 of the wound may be, the pins ought to pafs 
 within a very little of its bottom ; other- 
 wife the parts which lie deep will run a 
 rifk of not being united ; a circumftance 
 
 which 
 
32 Of Sutures . Chap. I. 
 
 which will frequently give rife to trouble- 
 fome colledlions of matter. 
 
 In paffing the pins through the difFererlt 
 fides of the wound, if the £kin and other 
 teguments are not more firm than ordi- 
 nary, it may commonly be done by the 
 fingers alone, and particularly if the pins 
 are made with fmall heads or knobs for 
 the fingers to prefs upon; but when firm- 
 nefs of parts and other circumftances ren- 
 der the entrance of the pins difficult, the 
 inftrument termed Porteaiguille very ef- 
 fetlnally removes this inconvenience. — In 
 Plate II. is reprefented the moft convenient 
 forn^ of this inftrument that has yet been 
 invented. 
 
 The firft pin being paiTed in this man- 
 ner very near to one end of the fore, 
 and the parts being ftill fupported by an 
 afiirtant, the furgeon, by means of a firm 
 waxed ligature paflcd three or four times 
 round and acrofs the pin, fo as nearly to 
 defcribe the figure ^f 8, is to draw the 
 parts through which it has pafTed into 
 clofe conta(5l ; and the thread being now 
 3 , fecured 
 
Plafe IT. 
 
 rJy^f^. ^ 
 
 y- 
 
 2. 
 
 ' ^/(/. ^- 
 
 3j,. 3. 
 
 II I 'Q 
 
 .^.^. 
 
 ^ 
 
 ,'^/.a//,f.y,/y 
 
Sea.V. Of Sutures, 33 
 
 now fecured wkh a loofe knot, another pin 
 mult be introduced in the fame manner at 
 a proper diftance from the former ; and 
 the thread with which the other was 
 fixed, being loofedj andin the fame man- 
 ner carried round this pin, others mud be 
 introduced at proper difhances along the 
 whole courfe of the v/ound, and the fame 
 ligature oughc to be of a fufficient .length 
 for fecuring the whole. 
 
 The number of pins to be ufed, mud 
 be determined entirely by the extent of the 
 wound. Whenever the futurCj however, 
 is pradlifed, whether the wound be large 
 or of very fmall extent, a pin ought to be 
 introduced very near to each end of it, 
 otherwife the extremities of the fore are 
 apt to feparate fo as not to be afterwards 
 eafily reunited. In large wounds, if the 
 pins be introduced at the diftance of three 
 quarters of an inch from one another, it 
 will in general be found fufficient j but, in 
 cuts of fmaller extent^ a greater number of 
 pins become neceffary in proportion to the 
 dimenfions of the fores. 
 
 Vol. 1. G Thus, 
 
34 Of Sutures. CHap. L 
 
 Thus, in a wound of an inch and halF 
 in length, three pins are abfolutely requi- 
 lite ; one near to each end, and another 
 in the middle of the fore : Whereas,, five 
 pins will always be found fully fufEcient 
 for a wound of three inches and a half in 
 extent, allowing one to be withui a quarter 
 of an inch of each extremity of the wound, 
 and the others to be placed along the eourfe 
 of the fore at the diflance of three quarters 
 of an inch from one another. 
 
 The pins being all introduced and fe- 
 Gured in the manner dlreded, nothings 
 remains to be done, but to aj)ply a piece 
 of lint wet with mucilage, all along the^ 
 eourfe of the wound, with a view to ex- 
 clude the external air as eiFed:ually as 
 poffible. 
 
 In order to prevent the ends of the pins 
 from prefTmg upon and hurting the fkin 
 below, it is ufual to apply a fmall bolfter 
 of linen or charpie under each of them ; 
 but as this always does mifchief, by tend- 
 ing to prefs upon the pins, fo as to force 
 them to adl upon the foft parts thro' which 
 
 they 
 
ChapiL Of Sutures, ^§ 
 
 they have pafTed, every thing of this kind 
 ought to be omitted. When, however, the 
 patient happens to complain of being hurt 
 by the ends of the pins, this may he eaiily^ 
 prevented by introducing between them 
 and the fkin pieces of thin linen fpread 
 with any adhefive plafler. 
 
 In order to give every chance of fuccefs 
 to this operation, it has been commonly 
 advifed, immediately after the pins are fe- 
 cured, to apply the uniting bandage over 
 the whole, fo as to afford as much fupporc 
 as poffible to the contiguous parts. The 
 leafl: reflection, however, renders itevidentj 
 that every degree of preffure made in this 
 manner muft do mifchief ; for, the bandage 
 being made to reft immediately upon the 
 pins, a confiderable degree of pain and 
 confequent inflammation muft of courfe 
 be produced by it : And in fad; this is fo 
 much the cafe, that, in every inftance in 
 which I have feen this bandage applied, ie 
 either did harm, by exciting inflammation 
 in confequence of too much preflure upon 
 the pins 5 or, if that effeel was not pro- 
 _ C a duced^ 
 
^6 Of Sutures, Chap.!'. 
 
 duced, no advantage was received from it,, 
 from the bandage not being applied wixh 
 fuch tightnefs as to afford any fupporc 
 whatever to the parts below. 
 
 The next paint to be determined, is, the 
 time the pins fhould be allowed to re- 
 main. When they remain long, they gene- 
 rally do harm, by the unrieceflary irritation 
 and confequent retraclion of parts with 
 which they are always attended; and again,. 
 if they are not continued for a fufficient 
 length of time, that degree of adhefion is 
 not produced between the divided parts 
 that is neceflary for their future retention, 
 fo that the ^^Q^t of the operation comes 
 to be in a great meafure, if not entirely, 
 loft. 
 
 In wounds of no great depth, for in- 
 ftance of about three quarters of an inch, 
 a fufBcient degree of adhefion always takes- 
 place in the fpaee of five days ; and fix, or 
 at mofl feven days, will generally be found 
 fufEcient for wounds of the greatefl depth. 
 
 But with refpecftto this cixGumftance, it 
 mufl always be underflood, that the pa- 
 patient's 
 
Sed. V. Of Sutures., 3 j 
 
 ■tient's (late of health will have a confider- 
 able influence on* the time necefTary for 
 producing adheiion between divided parts. 
 In fpecifying the time required for this 
 purpofe, the operation is fuppofed to have 
 been done in a found and healthy ftate of 
 the conflitution. When the patient la- 
 bours under any diforder which affecfls the 
 general fyftem, by cutaneous eruptions 
 or otherwife, it is impoflible to afcertain 
 this circumftance with precilion: In fuch 
 cafes we jnuft be determined by the na- 
 ture and ftate o'f the difeafe prefent at the 
 time. 
 
 As foon as the pins are withdrawn, the 
 uniting bandage may be applied with 
 great advantage in order to ferve as a fup- 
 port to the parts newly united; but, as 
 flips of leather fpread with ordinary glue, 
 when applied to each fide of the cicatrix, 
 may, by means of ligatures properly con- 
 ne(5led with them, be made to anfwer this 
 purpofe in a more effectual manner, this 
 mode of fapporting the parts ought of 
 -fourfe to be preferred. 
 
 Ca As 
 
^8 Of Sutures^ Cnap. !♦ 
 
 As the twlfted future when properly 
 performed is a very neat operation, as its 
 confequences are in general of irnportance, 
 and as it may with much advantage be 
 made to faperfede the ufe of almoft every 
 other future, a few inftances only excepted, 
 1 have therefore thought it proper to con^ 
 iider it with more attention than has hi- 
 therto been commonly beftowed upon it. 
 
 CHAP. II. 
 
 Of the Ligature of Arteries aftd other 
 means employed by art for putting a flop tQ 
 HEMORRHAGIEg. 
 
 TN every fpecie^ of wound, whether ac- 
 cidentally produced, or afFedted by the 
 hands of a furgeon, the firft circumftance 
 to be attended to, is the degree of hemor- 
 rhagy that takes place. In all fuch occur- 
 fenceSj thg blood is difcharged, either from 
 
Chap. ir. Of Arkrles^'&c, 3^ 
 
 ■one or more large arteries ; or, is produced 
 hj a general oozing from the fmaller vef- 
 fels over the furface of the fore : To the 
 former of thefe caufes we fliall firfl: attend, 
 and fhall afterwards proceed to the con- 
 lideration of the latter. 
 
 A furgeon being called to. a perfon lofing 
 much blood from the divifion of any of the 
 jarger veflels, the firfl: ilep to be taken, is, 
 -by means of ftrong compreflion, to efFe<^ 
 a temporary ftoppage of the difcharge, till 
 .by the application of ligatures a more ef- 
 fe(5lual remedy is obtained. In the head, 
 as well as in the trunk of the -body, the 
 eafiefl method of applying preiTare of this 
 kind, is, by means of doilils of lint or of 
 foft linen, held firmly tipon the mouths of 
 the bleeding veflels, either by the hands 
 ■oi an afUftant, or by the ufe of a proper 
 i)andage : Or, when preffure can be efFedlu- 
 ally applied to the fuperior part of the ar- 
 tery, it anfwers better ; as it not only fe- 
 cures the vefTel equally well, but admits of 
 $he neqeflary ligature being applied with 
 ^eater frje^om. 
 
 G 4 When, 
 
40 Of the Ligature Chap. II, 
 
 Wheiij again, accidents of this nature 
 occur in any of the extremities, and wher? 
 prefTure can be made with eafe on the fupe- 
 rior parts of arteries, for fuch cafes we are 
 m pofTeiTion of a remedy, which, when 
 fldlfuUy applied, never fails to put an im- 
 mediate ftop to all farther lofs of blood. 
 What is here meant, is^ the Tourniquet. 
 
 Till the invention of this inftrument, 
 which was not known before the lafl cen- 
 tury, Surgery remained extremely defecflive 
 indeed. No operation of importance could 
 be undertaken on any of the extremities 
 but with great hazard to the patient ; and 
 the efFedls of large wounds mufi frequently 
 have proved mortal, from the want of this 
 alTiflance, which otherwife might not have 
 been in any degree hazardous. 
 
 As the invention of the tourniquet is 
 claimed by difterenc perfons, and even by 
 different nations, we fliall not here pretend 
 to fay from whence it originally came : but 
 whoever had the merit of it, the firft inftru-^ 
 ment of this kind with which the world 
 was made acquainted, was exceedingly 
 
 fimplcs 
 
Chap, II. of Arteries^ t^c. 41 
 
 iimple ; fo mvicli fo, indeed, that it now 
 appears very furpriiing that the difcovery 
 fliould have been left for fuch a late pe- 
 riod. A fmall culhion being placed upon 
 the courfe of the principal artery of a limb, 
 a circular rope or bandage v^as made to pafs 
 twice round it; and a fmall wooden handle 
 being then introduced between one of the 
 folds of the bandage, for the purpofe of 
 twining it, the cufbion by thefe means was 
 prelTed with fo much force upon the artery, 
 as to put an efFeclual flop to the courfe of 
 the blood through the under part of the 
 limb. 
 
 Mr Petit, an eminent furgeon of Paris, 
 was the firft who propofed a confiderable 
 improvement on this inflrument, by con- 
 neding the circular bandage with a fcrew, 
 which was fo contrived as to produce the 
 prelTure chiefly on the principal arteries, 
 without materially affecfling the reft of the 
 limb. It had this advantage over the other 
 snftrument, that the operator himfelf could 
 ?n^ngge it, without being under the aecef- 
 
 fity 
 
42 Gf the Ligature Ghap.IL 
 
 iSty of employing an afTiftant ; but it was 
 •liable to one great inconvenience from 
 <:he very circumftance which by the inven- 
 tor was confidered as an improvement. 
 This inftrument of Mr Petit being made 
 to a6l upon the principal arteries only, the 
 Smaller veflels communicating with thefe, 
 by not being properly comprefled, dif- 
 charge blood freely "from the inftant they 
 are cut ; and as this proves a very trouble- 
 fome circumftance in the courfe of operas 
 tions, different improvements have of late 
 been made upon it. The pattern in Plate 
 HI. is the refalt of all thefe. 
 
 By means of this inftrument in its now 
 improved ftate, the blood in any limb is 
 very eafily and elfedually commanded ; and 
 as it grafps the whole member equally, all 
 the collateral brajiches as well as the prin- 
 cipal arteries are equally com preffed by it. 
 It has this material advantage, too, over 
 every other inftrument of this kind, that, 
 when properly applied, a fingle turn, or 
 €ven half a turn of the fcrew, is fu€iciemc 
 i^v producing either a flow of blood, or 
 
 for 
 
TlafeHr. 
 
 t^^-^. 
 
 e;/./.J,//rj'r,'//^ .^ 
 
Chap. II. of Arteries^ ^c, 43 
 
 for putting a total ftop to it.-— The man-*- 
 ner of uiing it is this. 
 
 Let a cuiliion of three inches in length 
 by one inch and half in diamecer, be pre- 
 pared -of a linen roller, and be made tole^- 
 rably firm, but yet not lb hard as to ren^ 
 der the prefTure produced by it very pain- 
 ful : This being placed upon the ccurfe of 
 the principal artery of the limb, is to be 
 firmly fecured in that fituation by one or 
 two turns of a circular roller, of the fame 
 breadth with the cufhion itfelf. 
 
 The inftrument A, with the firap con^ 
 nefled with it, being now placed upon the 
 limb, with the handle of the fcrew B on 
 the fide of the member oppoiite to the 
 cufliion upon the artery, the flrap C is to be 
 carried round the limb directly over the 
 cufliion, and to be firmly conneded on the 
 other fide to the buckle D. In thus connec- 
 ting the ftrap and buckle together, parti- 
 cular attention is necefTary in doing it with 
 great firmnefs, fo that the fcrew may after- 
 wards operate with as much advantage as 
 ppfiible, in producing a fuiEcient degree of 
 
 prefTure. 
 
44 ^f ^f^^ Ligature Chap. IL 
 
 prelTure. When proper attention is paid 
 to this circumftance, a fingle turn of the 
 fcrew, as we have faid, proves fufficient for 
 putting an entire ftop to the circulation 
 of blood in the limb : but when the ftrap 
 has not at firft been made very tight, fe- 
 'veral turns of the fcrew become necef- 
 fary ; an occurrence which may be always 
 €aiily prevented, and which, when not at- 
 tended to, proves often very embarraffing 
 in the courfe of an operation. 
 
 Whenever it is determined, therefore, 
 that any farther lofs of blood from a divi- 
 ded artery is to be prevented, preiTure on 
 the fuperiar part of the veiTel ought to 
 be immediately applied by the hands of 
 an afliftant, or a proper bandage, when the 
 cut is on the head or trunk of the body ; 
 and by means of the tourniquet, when any 
 of che extremities are wounded. 
 
 The patient being in this manner fecured 
 from immediate danger, the pracflitioner 
 mud now proceed to the eafieft and raoft 
 cffedual mode of preventing a return of 
 
 Jiemorrhagy 
 
Chap. IL of Arteries^ t^c. ' 4^ 
 
 liemorrhagy on the removal of the tourni- 
 quet. 
 
 The ancients, as we have feen, were ig- 
 norant of the ufe and application of the 
 tourniquet, and they were equally deiieiens 
 in the employment of means for giving 3 
 permanent fecurity againfl the flow of 
 blood from divided velTels: It will there- 
 fore readily occur to every modern prac- 
 titioner, that in this imperfedl flate of 
 Ghirurgical knowledge, when any capital 
 operations were attempted, they muft have 
 run a much greater rifk of doing mifchief, 
 than of procuring any advantage to their 
 patients. To the fmaller vefTels they ap- 
 plied doiTils of linen covered with aftrin- 
 gent powders ; and for the larger arteries, 
 fearing with hot irons was their only re- 
 iburce. 
 
 Of this lad remedy, however, although 
 it commands a temporary ftoppage of the 
 blood in every cafe of hemorrhagy, the 
 effeds are by no means to be depended on: 
 for, in general, the pulfation of the larger 
 arteries very foon overcomes all the reiift- 
 
 ance- 
 
H6 ' Of the Ligattm Gh«fJ.U, 
 
 snce produced by the application of ihd 
 cautery. 
 
 In ancient times, however, when this 
 •was the mod effedlual remedy with which 
 the world was acquainted, practitioners 
 were under the nsceffity of having recourfe 
 to it ; andj at that period, it is not furpri- 
 fing to find them exerciling their genius in 
 inventing a variety of ftyptic applications: 
 But fince furgery became enriched with 
 that material improvement of fecuring the 
 larger ar-teries by means of ligatures, a 
 pradice eafily effected, and with very little 
 pain to the patient, it is furprifing to find 
 that remedies of this kind are ftill fearched 
 after. If the ufe of ligatures were in itfelf 
 attended with much diiihculty, if by expe- 
 rience it had been found to be produ(5live of 
 many bad confequences, or, if it had been 
 frequently known to fail in anfwering as 
 a full fecurity againfl: the hemorrhagies of 
 the larger arteries ; in any of thefe events, 
 it ought to be the bufinefs of prad:itioners 
 to endeavour to procure a more effecfiual 
 remedy. Bur, .is the ligature of arteries is 
 3 very 
 
Cliap.II. of Arteries ^"^c. 4^7 
 
 7ery fimple in its nature ; a& the pain ari- 
 fing from it is trifling ; as few inftances 
 occur of any thing had being produced by 
 it ; and efpeeially as, when properly per- 
 formed, it never fails of proving a fure 
 preventative againft all lofs of blood from 
 the larger areeries ; there can be no good 
 reafon for anxioufly feeking after other re- 
 medies. 
 
 Agaric and other fungous fubCtances hjtve 
 been much extolled for their ftyptic powers ; 
 and chalybeate folutions, as well as all the 
 variety of mineral acids, have in difFerene 
 forms been held forth to the public as ef- 
 fedlual remedies of this nature ; not only 
 as noilrums by thofe of lefs liberal prin- 
 ciples, but, what is more furprifing, in fome 
 inftances by practitioners of chara6ler. 
 
 With the former clafs of men this hap- 
 pens as a common occurrence in the courfe 
 of their profeilion, and is therefore to be 
 expedled ; but a perfeverance in quefl of 
 any new remedy of this kind on the part 
 of Surgeons of reputation, who ar^ already 
 well acquainted with the effects of liga- 
 tures- 
 
4S Cf the Ligature Cnap.IL 
 
 tures in cafes of hemorrhagy, and who 
 alfo know that the pracfkice is feldom at- 
 tended with bad confequences, mufl pro- 
 ceed from a degree of nicety and refine- 
 ment, which may create much trouble to 
 ihemfelves, and which in all probabiUty 
 can never be produ6live of any pradlical 
 advantage. 
 
 We iliall therefore venture to lay it down 
 as an cflablifhcd maxim in furgery^ Thatin 
 every cafe of hemorrhagy from any of the 
 larger arteries, no ftyptic application what- 
 ever ought to be tnifted to, the ligature 
 being the only remedy to be depended on. 
 We now proceed therefore to the confedera- 
 tion of the eadeft and mod effectual mode 
 of carrying this application into execution. 
 
 Various methods have been invented for 
 fecuring arteries by means of ligatures. 
 The pra6lice now in ordinary ufe, is, by 
 means of a curved needle, to pafs a ligature 
 of fufficient flrength round the mouth of 
 the bleeding vefTel, including a quarter of 
 an inch^U round of the contiguous parts *, 
 1 and 
 
 * Sharp's Surgery — On Amputation. 
 
Chap. II. of Arteries^ %^c, 4^ 
 
 and afterwards to form a knot of a proper 
 tightnefs upon the veflel and other parts 
 comprehended in the noofe. 
 ' One great objecflion, however, to this me- 
 thod is, that the nerves accompanying the 
 blood-vefTels, together with a confiderable 
 portion of the mufcular fubftance through 
 which they pafs, mull: always be furround- 
 ed with every ligature formed in this man- 
 ner. From this circumftance much more 
 pain is produced than is necefTary, by the 
 nei^es and other parts being at the fame 
 time comprefTed with the arteries ; and, 
 on fome occafions, the fame caufe has evi« 
 dently given rife to violent convulfive af- 
 fections, not only of the part chiefly affedl- 
 ed, but of the whole fyftem. 
 
 Spafmodic twitches are frequently found 
 to occur after the amputation of limbs, and 
 are often the fource of much diftrefs. In 
 fome inftances they are no doubt to be 
 coniidered as the effed: of other caufes ; 
 but in various cafes it has happened, that 
 demonftrative proof has been obtained of 
 their arifing from the ligatures of arteries 
 Vol. I. D applied 
 
5© Of the Ligature Chap. I!. 
 
 applied in an improper manner. When 
 fuch convulfive affections occur after am- 
 pu cations, and the ufual means of pre- 
 venting them are found to fail, effedual 
 relief may be frequently obtained by de- 
 ftroying the ligatures altogether, fo as to 
 remove the compreffion upon the nerves ; 
 care being taken at the fame time to re- 
 new the ligatuEes upon the arteries imme- 
 diately, without comprehending any of the 
 contiguous parts. 
 
 Thus, it is not to the fimple ligature of 
 vefTels, but tc the improper manner in 
 which the operation is performed, that is, 
 the including of nerves and other parts, 
 inftead of tying the arteries alone, that the 
 bad fymptoms occurring in fuch cafes are 
 to be attributed. 
 
 Practitioners have commonly been afraid 
 of tying up blood-veffels by themfelves 
 without the intervention of fome of the 
 furrounding p?rts, onthisfuppofirion, that 
 the coats of arteries are not of fufficient 
 firmnefs to bear that degree of compref- 
 fion 
 
■fcliap. 11. of Arteries^ ^c, ^x 
 
 fion neceflary for the prevention of hemor- 
 rhagy. 
 
 This, however, originates from an idea 
 that the coats of arteries are not fo ftrong 
 as they really are ; and that a great de- 
 gree of force is neceflary for comprefling 
 their fides into clofe contaifl with one ano- 
 ther. 
 
 But it is now well known^ chat even 
 very fmall arteries are poiTeffed of much 
 firmnefs ; and it is alfo certain, that even 
 in the largell arteries of the arm or thigh, 
 a very flight degree of comprefTion is fully 
 fufficient, not only for reftraining hemor- 
 rhagy, but for fecuring the ligature on the 
 very fpot to which it is firft applied : And 
 in fmall veflels the force neceflary for this 
 purpofe is trifling indeed ; being far lefs 
 than is commonly applied. 
 
 Although the circumftance we are now 
 infifting upon may not at firft flght feem 
 to be of much importance, yet in fadl it 
 merits very particular attention. Even of 
 itfelf it is a matter of no fmall confe- 
 quence, but it is the more material when 
 D 2 we 
 
5 2 Of the Ligature Chap.lL 
 
 we confider it as connecled in many in- 
 ftances with circumftances on which the 
 life of a patient may in a great meafure 
 depend ; and we know well too, that fuc- 
 cefs in furgical operations depends more 
 on a minute attention to every circum- 
 ftance relating to them, than on particular 
 dexterity in any one part of them. 
 
 It has alfo been objected to this mode of 
 fecuring blood-vefTels by themfelves, that 
 the ligatures, although they fliould not cut 
 the arteries through, yet that they are 
 more apt to flip than when fome of the 
 furrounding parts are comprehended along 
 with them ; and, in fome inftances, it is 
 faid that arteries retracft fo far, that they 
 cannot in any other way be laid hold of, 
 than by means of the crooked needle in 
 the ordinary method. 
 
 Long and repeated experience, however, 
 of a few individuals, in regard to this mode 
 of taking up arteries by themfelves, has 
 put the fa6t beyond a doubt, that it is 
 as fecurc as any other yet invented *. — 
 
 • Fatal 
 
 * See an efiay upon this fubje£t, by the ingenious 
 Mr Aitken, furgeon in Warrington, 
 
Chap. II. of Arteries ^"zic, 5j 
 
 Fatal hemorrhagies after capital opera- 
 tions, either from inattention, or fome 
 other caufe, do now and then indeed hap- 
 pen in the hands of the moft able pradi- 
 tioners; but occurrences of this nat^re 
 have as frequently happened when the 
 curved needle was employed, as when the 
 blood- veflels were fecured by themfelves 
 without any of the contiguous parts being 
 included. 
 
 From the refult of my own experience, 
 indeed, I fhould be induced even from 
 this confideration, to draw a conclufion 
 in favour of the method we have been en- 
 deavouring to recommend. For, in the 
 courfe of pradlice, both among hofpital pa- 
 tients and in private, I have known different 
 deaths occur from the bleeding of (lumps 
 after the amputation of members : Whether 
 this proceeded from the ligatures having 
 flipped from fome of the arteries ; or from 
 this circumftance, that fome of the velTels 
 which did not appear during the operation, 
 had been of courfe paiTed over without be- 
 ipg obferved and had afterwards burft out> 
 D 3 I 
 
r^ Of the Ligaturs Chap.H^ 
 
 I fhall not pretend to determine : but in all 
 of tnefe, the crooked needle only had been ufed 
 during the operation ; and it has lb hap- 
 pened, that 1 never met with a fiiigle in- 
 ftance of a fiunlar occurrence where the 
 arteries were fecured by themfelves by 
 means of the tenaculum ; an inflrument to 
 be afterwards taken notice of. 
 
 In a few inllances it may happen, that 
 a bleeding veilel, from lying at the bottom 
 of a deep wound, cannot be laid hold of 
 in any other manner than by the curved 
 needle being made to pafs round it. Such 
 occurrences, however, are exceedingly rare: 
 infomuch that I have feldom known an 
 inftance in which hemorrhagy could not 
 be as effe(!^ually reftrained by the mode 
 now to be pointed out, as by the ufe of 
 the crooked needle. 
 
 ir 
 
 In ail operations whatever, to lave unne- 
 cefTary pain ought to be a very capital ob- 
 je6l. In every budnefs of this kind, the 
 objecft in view ought no doubt to be at- 
 tained in the moil complete manner; but 
 that mode of operation, v^^hich is as com- 
 plete 
 
Chap. II. oC Arterm^ cffr. 55 
 
 plete as any other, at the fame time that 
 it is the lead painful to the patient, is un- 
 doubtedly in every inftance to be pre- 
 ferred. Now, with refpec5l to the point in 
 queftion, as we have already clearly fhown, 
 that arteries may be tied with as much 
 fafety in every refpedl, by themfelves, as 
 when ccnnedled with any of the neigh- 
 bouring parts, the difference of pain pro- 
 duced by the two modes of operating, 
 ought at once to determine in favour of 
 the former. 
 
 When any of the contiguous parts, par- 
 ticularly when the nerves which generally 
 accompany the blood- veffels, are included 
 in the fame ligature with an. artery, which 
 when the curved needle is employed is a 
 circumftance fcarcely to be avoided, every 
 pradlitioner knov/s that tying the knot 
 in this manner is frequently complained 
 of by the patient in very fevere terms. I 
 have on many occafions known patients 
 who have borne the amputation of limbs, 
 and of cancerous breads, without fhrink- 
 ing, complain bitterly of the fevere pain 
 D 4 pro=^ 
 
56 Of the Lignture Chap.lL 
 
 produced by the method of fecuring arte- 
 ries with the crooked needle. And on the 
 contrary, the pain attending the method 
 now propofed, is fo trifling, that, when 
 properly done, even the mod timid patients 
 very feldom complain of it. 
 
 For fome time after I firft began to 
 ufe the tenaculum, curiofity induced me, 
 on different occafions, to put the matter 
 nnder coniideration to the ted of experi- 
 ment : And to render the trial as fair and 
 decifive as poffible,, it was always made 
 upon the fame fubjed, undeA' the fame 
 operation. Different vefTels were fecured 
 in the ordinary manner by the crooked 
 needle; whilft others were laid hold of by 
 the tenaculum : But fo great was the dif- 
 ference in point of pain, that the one 
 was uniformly allowed to give very little 
 vmeafinefs : whereas it frequently hap» 
 pened, that the other was complained of 
 as the mod painful part of the whole ope- 
 ration. 
 
 Among other advantages which the ty- 
 ing of arteries by means of the tenaculum 
 
 has 
 
Chap. II. of Arteries^ ^c, 57 
 
 has over the old mode of operating, - there 
 is flill one we have not yet taken notice of. 
 It often happens after amputations, and 
 other operations where the larger arteries 
 have been tied, that the ligatures do not 
 come eafily away, from being made to run 
 fo deep as with the curved needle is com- 
 monly necelTary. In fome inftances much 
 pain and trouble has occurred from this 
 circumftance, the ligature remaining quite 
 immoveable for a great many weeks: And 
 after all, 1 have feen it necelTary for the 
 furgeon, to put the patient to a great deal 
 of pain, by being obliged to cut out the 
 threads wich a fcalpel. But when the te- 
 naculum is ufed, every rifk of this kind 
 is avoided, from the ligatures generally 
 dropping of their own accord, in the 
 courfe of the third or fourth dreffing of 
 the fore. 
 
 From what has been faid, therefore, we 
 iliall confider it as a pra6lice that ought to 
 be ellabiifhed, that in formine; the ligature 
 of arteries, the nerves and other contiguous 
 parts fliould be carefully avoided. , 
 
 For 
 
58 Of the Ligature Chap. II. 
 
 For the purpofe of afFe6llng this with 
 cafe and fafety, various kinds of the inftru- 
 ment termed a Forceps have been invented ; 
 with thefe, the arteries of a fore are laid 
 hold of and pulled out, fo as to admit of 
 the application of ligatures. 
 
 For the larger blood- veffels, the forceps 
 has been found to anfwer conveniently 
 enough ; but, in the fmaller arteries, they 
 are by no means fo fit for the purpofe as 
 the inftrument or hook I have been recom- 
 mending, termed a Tenaculum, andrepre- 
 fenced in Plate 1. And as a hook of this 
 form anfwers equally well in the larger ar-^ 
 teries likewife, the ufe of the forceps may 
 therefore be laid entirely aiide, • The man-* 
 per of uling the tenaculum is this. 
 
 In order to decedl the arteries to be 
 tied, the tourniquet with which they are 
 fecured, muft be llackened a little by a 
 turn or two of the fcrew ; and the moment 
 the largeft artery of the fore is difcovered, 
 the furgeon fixes his eye upon it, and im- 
 mediately reftrains the blood again by 
 jjieans of the tourniquet. An alTiftant 
 
 now 
 
Chap, II. of Arteries^ ^c, 59 
 
 now forms a noofe on the ligature to be 
 made ufe of; and this noofe being placed 
 immediately over the end of the artery, 
 fo as to include it with <:ertainty, the ope^ 
 rator then pufhes the iliarp point of the 
 tenaculum through the (ides of the veflel, 
 and at the fame time pulls fo much of it 
 out, over the furface of the furrounding 
 parts, as he thinks it fuincient to be in- 
 cluded in the knot which the afliftant is 
 now to make. In forming this ligature, 
 the furgeon's knot, as it is termed, which 
 confifts in paffing the thread twice through 
 the firlf noofe is certainly preferable to 
 every other, from its being lefs liable to 
 yield or flip. And as fome additional fe- 
 curity is obtained by forming a fecond 
 knot above the firft, this precaution ought 
 never to be omitted. It is eaiily done; and 
 on fecurity in this point the patient's life 
 may in a great meafure depend. 
 
 The degree of ftrength of the ligature 
 mud always be proportioned to the fize of 
 the velTels ; but this is acircumflance to be 
 ^t all times determined by the judgement 
 
 I of 
 
Go Of the Ligature Chap. II. 
 
 of the pradlitioner, as muft alfo the force 
 to be employed in forming the knots. To 
 what was already faid upon this point I 
 iliall juft add, that a very fmall force is fully 
 fufEcient for fecuring even the largefl ar- 
 teries : and that, after fuch a force has 
 been applied as evidently reflrains the far- 
 ther lofs of blood, a very trifling additional 
 compreflion is all that is necefTary. 
 
 The principal artery being in this man- 
 ner fecuredj all the vefTels of the part mnfl: 
 one after another be taken up in the fame 
 manner, by firfl loofening the tourniquet 
 in order to difcover them, and afterwards 
 applying the ligature to each in the man- 
 ner direcfled. 
 
 It often happens, however, that the lofs 
 of blood the patient has fuftained ; a ten- 
 dency to delinquium which may take place 
 for the time; the fear he labours under; and 
 the degree of cold to which the fore is ex- 
 pofed, have altogether fuch an efFe(fl upon 
 the fmaller arteries, as to prevent them for 
 the time from difcharging their contents ? 
 and as arteries left in fuch a flate without 
 
 being 
 
Chap. It, of Arteries^ ^c, 6f 
 
 being fecured, generally burft out on the 
 removal of thefe caufes, a cuxumflance 
 which always occafions much trouble to 
 the pra(flitioner, as well as a great deal of 
 pain and riilc to the patient, every fur- 
 geon ought to pay the niceft attention to 
 this point. 
 
 The tourniquet fhould be made perfedl- 
 ly loofe ; any coagulated blood on the fur- 
 face of the fore ought to be carefully 
 wafhed off with a fponge and warm wa- 
 ter ; and the patient, if faintilh, ought to 
 get a glafs of wine, or fome other cordial ; 
 and after all, the furgeon ought to exa- 
 mine, with the moft minute attention, the 
 ufual courfe which the veffels of the pare 
 are known to take. 
 
 This being done, every artery of the 
 part, even the fmallell that can be diftin- 
 guifhed, ought to be fecured with a liga- 
 ture : For fuch vefTels as appear exceeding- 
 ly trifling while the part is yet expofed to 
 the air, nay even the fmall branches of 
 arteries that happen to be negiedled, wiji 
 be capable of difcharging very conuder- 
 
 able 
 
62 Of the Ligalun Chap, tl, 
 
 able quantities of blood after the patient 
 becomes warm in bed, when the Iblids 
 are thereby relaxed and the fluids ex- 
 panded ; and,, as little or no injury can 
 ever be done by the proper application of 
 ligatures to all the arteries that prefenc 
 themfelves, the greateft attention ought 
 at all times to be paid to this circum- 
 llance. 
 
 I have infifted the more on this, from 
 having frequently obferved much uneafi- 
 nefs and diftrefs produced by a want of 
 proper attention to this part of an opera- 
 tion, 
 
 When the principal arteries of a flump 
 have been taken up, and a little blood con- 
 tinues to be difcharged, but appears to 
 come from a few fmall veflels only, the 
 furgeon, unlefs he is much accuftomed to 
 occurrences of this nature, is induced to 
 think, that as they are very trifling to ap- 
 pearance, fo he need not be at the trouble 
 of tying them, as the neceflTary comprefllon 
 of the bandages proper for the wound wilt 
 in all probability efle<5t a total i\oppage of 
 
 die 
 
Ghap.II. of Arteries ^^c, 6^ 
 
 the hemorrhagy. In a general oozing of 
 a fmall quantity of blood from the whole 
 furface of a fore, and when no particular 
 vefTel can be diilinguilhed, there is a ne- 
 ceffity for trufling to this remedy ; but, 
 whenever an artery can be difcovered, of 
 whatever fize it may be, it ought unque- 
 ftionably to be fecured by a ligature. Ie 
 very rarely happens that any inconvenience 
 occurs from ligatures when properly ap- 
 plied; but many lives have been loft from 
 a remiffnefs in this article. 1 have known 
 different inftances of this, and the fame 
 muft have occurred to others. 
 
 When, from thedeepnefs of a wound, or 
 from any other caufe, fome particular arte- 
 ry cannot be properly fecured by the tena- 
 culum; in this cafe we are under the necef- 
 fity of employing the crooked needle, and 
 the following is the mode of ufing it. 
 
 The operator ought to be provided with 
 needles of various fizes, and of different 
 forms. The needle in ordinary ufe, are 
 for many purpofes quite too much-cjooked; 
 for, in general, they are more eafily ma- 
 naged 
 
(j4 Of the Ligature Chap. If, 
 
 nagcd when their curvatures are not fo 
 coiifiderable. 
 
 The fame kinds of needles that are found 
 neceflary for the interrupted future, as re- 
 prefeiited in Plate 1. anfvver equally well 
 for the ligature of arteries. 
 
 The needles in common ufe are made 
 triangular with three edges, one on each 
 fide, and a third on the concave part of 
 the needle. There is no real neceflityj 
 however, for more than two : Indeed 
 the needle enters more ealily with two 
 than with three edges ; and as the third 
 edge on the concave fide, renders them 
 jnore liable to injure arteries and other 
 parts in the courfe of their introdudion, 
 this addition ought to be omitted. 
 
 A needle of this fliape, armed with a li- 
 gature of a fize proportioned to itfelf and 
 to the velTel to be taken up, is to be intro- 
 duced at the diflance of a fixth or eighth 
 part of an inch from the artery, and pufli- 
 ed to a depth fufficient for retaining it, at 
 the faiKe time that it is carried fully one- 
 half round the blood- veiTel. It mufl: now 
 I be 
 
Ghap. II. of Arteries^ 6^r. ^^ 
 
 be drawn out; and being again pufhed 
 forward till it has completely encircled 
 the mouth of the artery, it is then to be 
 pulled out, and a knot to be tied of a fuf- 
 ficient firmnefs, as was already dire(5ted 
 when the tenaculum is ufed. 
 
 In this manner, either by the ufe of 
 the crooked needle, or of the tenaculum, 
 evdry hemorrhagy depending upon a di- 
 vifion of one or more large arteries, may 
 in general be very eafily retrained; but 
 it frequently happens, that confiderable 
 quantities of blood are difcharged, not 
 from any particular veflel, but from all 
 the fmall arteries over the furface of the 
 fore. In wounds of great extent, particu- 
 larly after the extirpation of cancerous 
 breafts, and in other operations where 
 exteniive fores are left, this fpecies of he- 
 morrhagy often proves very troublefome 
 from being exceedingly difficult to fup- 
 prefs. 
 
 Bleedings of this kind feem evidently to 
 proceed from two very different andoppo- 
 fite caufes ; a circumftance which, in the 
 
 Vol. I. E treat- 
 
66 Of the Ligature Chap. II. 
 
 treatment of them, is a matter requiring 
 very particiilar attention. 
 
 First, We now and then find efFufions 
 of this nature occurring in ftrong robuft 
 people, where they evidently proceed, either 
 from too great a quantity of blood contain- 
 ed in the veflels, or from an excefs of cone 
 in the veffels themfelves; or, perhaps, from 
 a combination of both thefe caufes- But, 
 Secondly, Such evacuations undoubtedly 
 happen moft frequently in conftitutions 
 quite the rcverfe of the former, viz. in fuch 
 as are very relaxed and debilitated; either 
 from a putrid diffolved ftate of the bloody, 
 or from a w^ant of tone in the containing 
 veflelsj or in fome inflances from a con- 
 currence of both. 
 
 In conftitutions perfcclly healthy, when 
 the fluids are not tainted with any degree 
 of putrefcency, and the folids are pofTefled 
 of their natural tonic powers, on the oc- 
 currence of v/ounds even of the mofl ex" 
 tenfive nature, as foon as the larger arte- 
 ries are fecured, all the fmall veflels thac 
 have been divided, in confequence of that 
 
 con- 
 
Chap. ir. of Arteries^ Iffc, 6y 
 
 contra6lile power with which in a ftate of 
 health they are endowed, and from the fti- 
 mulus of the external air to which they 
 iare now expofed, are diminilhed not only 
 in their diameters, bntalfo in their length ; 
 in confequence of which, they recede con- 
 fiderably within the furface of the fur- 
 rounding parts. 
 
 This caufe of itfelf would probably in 
 the greateft number of inftances prove 
 fufEcient for reftraining all lofs of blood 
 from the fmaller arteries ; but in the found 
 (late of conftitution of which we have now 
 been fpeaking, another very powerful agent 
 is provided by nature for producing the 
 fame effed. From the extremities of the 
 divided veflels which at firft difcharged 
 red blood only, there now, in their con- 
 tradled flate, oozes out a more thin, though 
 Vifcid fluid, containing a certain propor- 
 tion of the coagulable parts of the blood; 
 and this being equally diftributed over the 
 furface of the wound, by its balfamic ag- 
 glutinating powers, has undoubtedly a very 
 E 2 con- 
 
58 Of the Ligature Chap.TI. 
 
 confiderable influence in reilraining all fuch 
 hemorrhagies. 
 
 In conflitutions altogether healthy, where 
 neither of the dates of difeafe we have al- 
 luded to preponderates over the other, we 
 find, that, as foon as the larger arteries of 
 wounds are fecured, nature, in the manner 
 already defcribed, generally puts a (lop to 
 all farther diicharge. So that, whenever 
 the contrary happens, by a tedious oozing 
 continuing from the furface of the fore, 
 we ought then to pay particular attention 
 to the habit of body with which it is con- 
 nscled. 
 
 When fuch an occurrence happens in a 
 p.itient, young and vigorous, and where 
 the tone of the mufcular fibres is evidently 
 great, the moft effectual means of putting 
 a flop to the difcharge, is to relax the vaf- 
 cular fyfkem, either by opening a vein in 
 fome other part, or, what gives ftill more 
 immediate relief, by untying the ligature 
 on one of the principal arteries of the part, 
 fo as to allow it to bleed freely: Thofe vio- 
 lent fpafmodic twitchings too, fo frequent 
 
 after 
 
Ghap. IT. of Arteries^ ^c, 69 
 
 after operations on any of the extremities, 
 when they do not depend on a nerve being 
 included in the "ligature with the artery, 
 are in this manner more effedtually relie- 
 ved than by any other means. 
 
 By the fame means, the patient, from 
 being in a febrile heat and much confufed, 
 foon becomes very tranquil: The violent 
 pulfation of the heart and larger arteries 
 abates, and the blood not being propel- 
 led with fuch impetuofity into the fmaiier 
 velTels of the part, they are thereby left 
 at more liberty to retradl ; and as in this 
 ftate they do not pour forth red blood fo 
 freely, they are the more readily covered 
 with that vifcid glutinous fluid which we 
 have already fliown to be one of the moft 
 important means intended by nature for 
 the prevention of fuch hemorrhagies. At 
 the fame time that by the means recom- 
 mended we endeavour to allay the com- 
 motion- produced in the fyftem, the patient 
 ought to be kept exceedingly cool; wine 
 and other cordials fnould be rigidly avoid- 
 ed ; cold water, acidulated cither with th-e 
 E ; - mineral 
 
70 Of the Ligature Chap. 11, 
 
 mineral or vegetable acids, ought to be 
 the only drink ; motion of every kind, 
 parcicularly of the part affecled, fliould be 
 guarded againft; and the wound being 
 gently covered with lint or foft charpie, 
 ought to be tied up with a bandage fo ap- 
 plied as to produce a moderate degree of 
 prefTure on the extremities of the divided 
 parts. 
 
 In every extenfive wound attended with 
 hemorrhagies of this kind, and particularly 
 ■when violent fpafmodic afFe6tions of the 
 mufcles fupervene together with the means 
 already recommended, large dofes of opi- 
 ates are found highly beneficial; for what- 
 ever hurtful effe(5ls may have been appre- 
 hended from opiates in fome inflamma- 
 tory afFedlions, every pradlitioner who has 
 ventured on a free ufe of them muft ad- 
 mit, that in all occurrences of this nature 
 their influence far furpaiTes that of any 
 other remedy. 
 
 As foon therefore as a fufKcient quan- 
 tity of blood has been difcharged, and the 
 wound is drefTed and the patient laid to. 
 
 reft. 
 
Chap. IL of Arteries^ l5fc, yi 
 
 reft, a dofe of opium proportioned to the 
 violence of the fymptoms ought to be ex- 
 hibited. It lliould be remarked, how- 
 ever, that, in all fach circumflances, much 
 larger dofes of the remedy are neceffary, 
 than in ordinary cafes requiring the ufe 
 of opiates. Small dofes, inftead of an- 
 fwering ^ny good purpofe, feem fre- 
 quently rather to aggravate the various 
 fymptoms ; fo that, whenever they are 
 here employed, they ought always to be 
 given in quantities fufEcient for the in- 
 tended eiFecfl. 
 
 Although hemorrhagies of this nature 
 do now and then occur in firm vigorous 
 conftitations; yet they undoubtedly hap- 
 pen much more frequently in relaxed en- 
 feebled habit«, where the folids have loft 
 part of their natural firmnefs, and the fluids 
 have acquired feme degree of putrefcency. 
 As the veffels in this iituation are fuppofed 
 to have been deprived of that degree of 
 tone of which we wiin them to be pofTef- 
 fed, inftead of reftraining the patient from 
 ^he ufe of cordials, as is done ufually in 
 E 4 every 
 
72 Of the Ligalure Chap. 11. 
 
 every cafe of hemorrhagy, a moderate ufe 
 of generous wine ought to be immediately 
 prelcribed; for nothing, it may be obfer- 
 ved, tends fo much in fuch circumflances 
 to reflrain hemorrhigies, as awell-direcled 
 uie of proper cordials. By intending to in-r 
 vigorate and brace the folids, they thereby 
 enable the arterial fyftem to give a due 
 reliftance to the contained fluids; and the 
 fame caufe, it may be obferved, has a con- 
 fiderable influence in refloring to the fluids 
 that vifcidity ofwhichinall fuch inftances 
 we fnppole them to be deprived. 
 
 Whenever, therefore, fuch tedious he- 
 morrhagies occur in relaxed debilitated 
 habits, a free ule of Port, Madeira, or any 
 other wine whofe flrength and gaodnefs 
 can be depended on, ought to be immediate^ 
 ly allowed; a nouriihing diet alfo becomes 
 proper; the patient ought to be kept cool; 
 and the mineral acids, from their known 
 litility in every fpecics of hemorrhagy, 
 ought alfo to be prefcribed. Red of body 
 is here proper too; and opiates, when in- 
 dicated either by pain or fpafmodic affec- 
 tions 
 
N 
 
 Chap. lie Of Arteries^ ^c _ y^ 
 
 tions of the mufcles, ought never to be 
 omitted. 
 
 Together with thefe remedies adapted 
 to the general fyftem, particular dreffings, 
 appropriated to the flate of the parts to 
 which they are to be applied, have been 
 found very beneficial. We have already 
 remarked, that in firm healthy conftitu- 
 tions, as foon as the difcharge of blood 
 which naturally occurs in every large 
 wound is over, the parts come foon to be 
 covered with a vifcid coagulable effufion 
 from the months of the now retradled ar- 
 teries; but in conftitutions of an oppofite 
 nature, where the folids are much relaxed, 
 the blood in general is found in fuch a 
 difiolved (late as to afford no fecretion of 
 this nature. 
 
 In order therefore to fupply as much as 
 poflible the deficiency of this natural bal- 
 fam, different artificial applications have 
 been invented. Dulling the parts with 
 ftarch or wheat-flour has fometimes been 
 found of ufe; and I have known gum 
 
 arable 
 
74 Of the Ligature Chap. 11. 
 
 arable in fine powder to anfwer when 
 thefe have failed. 
 
 Applications of this kind, indeed, have 
 been ufed with fuccefs in all fuch hemor- 
 rhaghies, with whatever habit of body they 
 happen to be conne(5led ; but they have al- 
 ways proved more particularly ferviceable 
 in relaxed conftitutions, attended with a 
 diffolved (late of the blood and an enfeebled 
 mufcular fyftem. We may here ufe with 
 freedom too, a remedy which in fuch cir- 
 cumftances generally proves ferviceable, 
 but which in conftitutions of an oppofite 
 nature ought never to be employed. The 
 remedy alluded to is alcohol, or any other 
 ardent fpirits, impregnated with as great a 
 quantity as they can difTolve of myrrh or 
 any other of the heating vifcid gums. The 
 balfamum traumaticum of the fhops, a re- 
 medy of this nature,' has long been famous 
 for its influence in fuch cafes : but that in- 
 difcriminate ufe of this and fimilar applica- 
 tions which has long prevailed with fome 
 pracflitioners, I am confident has done much 
 harm j for, as they are all pofTefled of very 
 
 ftimulating 
 
Chap. II. Of Arteries^ tffc, j^ 
 
 ftimulating powers, they of courfe tend to 
 aggravate every fymptom in wounds con- 
 nedled with a tenfe flate of fibres, when 
 much pain, and efpecially when fpafmodic 
 mufcular affedions, prevail. But, in con- 
 flitutions of an oppofite nature, where the 
 blood appears to be in a dilTolved flate, and 
 where the arterial fyftem feems evidently 
 to require a ftimulus, remedies of this clafs 
 come to be very ufeful : Infomuch that, in 
 every conftitution of this kind where he- 
 morrhagies prove troublefome, no appli- 
 cation whatever is found to anfwer better, 
 than charpie immerfed in an agglutinating 
 fpirituous balfam of this nature. 
 
 By a due perfeverance in one or other of 
 the plans here pointed out, it will feldom 
 happen that hemorrhagies of this nature 
 are not at laft reftrained: But when the 
 contrary does occur; when, notwithfland- 
 ing the ufe of the remedies recommended, 
 a difcharge of blood ftill continues; to- 
 gether with the means already advifed, an 
 equal moderate prelTure ought to be ap- 
 plied over the whole furface of the fore, to 
 
 be 
 
y6 Of the Ligature^ Effr. Chap. IL 
 
 be continued as long as the ndcefTity of the 
 cafe feems to indicate. 
 
 In finifliing the dreflxngs of fuch wounds, 
 after the charpie and compreiTes have been 
 applied, a bandage ought to be adapted to 
 the part in fuch a manner as to produce 
 as equal a degree of prefTure over the fur- 
 face of the fore as poflible. But it fome- 
 times happens, that no bandage whatever 
 can be fo applied as to produce the defired 
 efFecfl; and in fuch cafes, the hand of an 
 affiftant is the only refource. In fuch in- 
 flances, a perfon's hand being firmly ap- 
 plied over the drellings, fo as to produce a 
 very equal degree of prefTure, will com- 
 monly fucceed when no other remedy is 
 found to have much influence. 
 
 Having thus endeavoured to point out 
 the mofl effedlual means of putting a flop 
 to morbid hemorrhagies, v/e fhall now 
 proceed to confider the different modes em- 
 ployed by art, for efFedling a difcharge of 
 blood when indicated by the prefence of 
 of fome diforder in the conflitution. 
 
 t CHAP, 
 
Sea. I. Of Blood'kttmg. 7/ 
 
 CHAP. III. 
 cy Blood- LETTING. 
 
 SECTION I. 
 Of Blood-letting in general, 
 
 T>LOOD-LETTiNG, whether we confider 
 it as to its influence on the fyftem, or 
 with refpedl to the nicenefs and even dif" 
 ficulty of the mode ufually employed for 
 efFedling it, is perhaps one of the moft im- 
 portant operations in furgery. From its 
 being fo frequently put in pradice, and 
 from every pretender to any knowledge in 
 the healing art being able to perform it 
 without any apparent difficulty, the pub- 
 lic have been induced to confider it as 
 trivial with refpecl to its execution ; but 
 every pra(5litloner of charadler muft ac- 
 knowledge, that, in order to perform this 
 
 operation 
 
98 Of Blood-letting. Chap. IlL 
 
 operation properly, the greateft nicety, 
 fleadincfs, and exa^lnefs, are necefPary. All 
 the other operations in furgery I have fre- 
 quently feen well performed ; but I can 
 with freedom fay, that I have feldom feen 
 blood-letting with the lancet done very cor- 
 redly : When properly performed, it is 
 really a neat operation ; biit when not done 
 with exadtnefs, it is the very reverfe. 
 
 It is not here meant to enter into the 
 confideration of the various caufes which 
 in different circumftances point out the 
 propriety of abflracling blood from the 
 fyflem ; nor is it intended to enter upon a 
 particular difcuffion of the different effedls 
 produced by general and topical blood-let- 
 ting: Thefe confiderations, as being highly 
 important, would of themfelves extend to 
 a very great length ; and beiides, are of fuch 
 a nature as renders it impoflible to enter 
 mirmtely upon their difcuflion in any fy- 
 ftem of furgery. All that is here intended, 
 its to defcribe as clearly as poffible the va- 
 rious modes of performing the operation 
 of blood-letting. 
 
 in 
 
Sea. I. of Blood-letting. 79 
 
 In all inflammatory afFecftions produ- 
 cing a general diforder of the fyltem, the 
 method of taking away blood as now efta- 
 bliflied by immemorial practice, is, by 
 fuch means as difcharge the quantity to be 
 taken in a fliort fpace of time, by an open- 
 ing made with a lancet, either in an artery 
 or in a vein. Whether there is any real 
 difference in the efFecfts produced by thefe 
 two modes of difcharging blood, it may 
 be difficult to determine with any preci- 
 iion ; but there is reafon to fuppofe, that, 
 independent of the quantity taken, the 
 difference is of lefs importance than is 
 commonly imagined. The latter of thefe 
 termed Phlebotomy, and the former Ar- 
 teriotomy, are the means employed for 
 what we term, general blood-letting; the 
 particular confideration of which we fhall 
 prefently attend to. 
 
 But it often happens, in diforders of an 
 inflammatory nature, where there is evi- 
 dently a fixed local affecflion, and where 
 no great degree of fever takes place, that 
 general blood-letting has not much infiu- 
 3 ence 
 
So Of Blood-letting, Chap. IIL 
 
 ence in midgating the fymptoms ; and in 
 fuch circumftances confiderable advantage 
 is frequently obtained by difcharging blood 
 from the part immediately afFeCled, by di- 
 viding a number of the fmall velTels which 
 fupply it ; and this we term Topical or 
 Local blood-letting. The means employed 
 by art for difcharging blood in this man- 
 ner fhall be afterwards treated of, and we 
 now return to the particular confideration 
 of phlebotomy. 
 
 Wherever a vein of a tolerable fize can 
 be reached with fafety, an opening for the 
 difcharge of blood may be made in it with 
 a lancet ; but the following are the parts 
 from whence blood is ufually taken in this 
 manner ; viz. from the veins of the arm 
 at the flexure of the cubitus ; from the 
 jugular veins ; and from the veins of the 
 ankles and feet. On particular occafions, 
 too, blood is advifed to be taken from the 
 veins of the hand, of the tongue, &c. 
 
 There are fome general rules and obfer- 
 vations which relate equally to this opera- 
 tion in whatever part of the body it is prac- 
 
 tifed J 
 
iSea. I. Of Blood-letting, 8 1 
 
 tifed ; tliefe we fhall in the firfl: place point 
 out with as much accuracy as poflible, 
 and fhall afterwards proceed to treat par- 
 ticularly of blood-letting in the arm and 
 other parts. 
 
 I. In this as in every other operation, 
 the fituation of the patient, and of the ope- 
 rator likewife, ought to be precifely fixed. 
 As the fituation of a patient during the 
 operation of blood-letting, has a conQder- 
 able influence on the effeds produced by 
 the evacuation upon the fyftem, this cir- 
 cumftance therefore merits our particular 
 attention. In fome diforders, it is the ohjetfi: 
 of this remedy, to evacuate a confiderable 
 quantity of blood without inducing faint- 
 ing : When this is the cafe, and when from 
 former experience it is known that the 
 patient to be operated upon is liable du- 
 ring the evacuation to fall into a faintilli 
 ftate, a horizontal pofture, either upon a 
 bed or on a couch, ought to be preferred to 
 every other ; for every praditioner is now 
 well acquainted with this fa6, that faint- 
 . Vol I. F ' inj? 
 
82 Of Blood'kttlng. Chap. lit 
 
 ing does not To readily occur in a horizon- 
 tal as in an ere^l pofture. 
 
 It now and then happens, however, that 
 one material advantage expe^ed from the 
 operation of blood-letting, is the inducing 
 a ftate of deliquium ; as for inftance, in 
 cafes of flrangulated hernia, where a ge- 
 neral relaxation of the fyftem is fometimes 
 defirable. In all fuch circumitances, in- 
 flead of a horizontal pofture, the more 
 erecft the patient is kept, the more readily 
 will a (late of fainting be induced : So 
 that the particular object in view from the 
 operation, mufl at all times determine this 
 iTiatter. 
 
 While we thus attend particularly to 
 the poflure of the body at large, the particu^ 
 lar poiicion of the limb or part to be ope- 
 rated upon muft not be negledled. In 
 every operation, it is a matter of much 
 importance to have the patient feated in 
 a proper lights but in none is it more 
 material than in blood-letting. The bell 
 general rule that can be given upon this 
 point is, that the patient ought to be fo 
 3 placed? 
 
Seel. T. Of Blood-letting. 83 
 
 placed, as that the principal light of the 
 apartment fhall fall direclly upon the part 
 to be operated upon, fo that the vein to be 
 opened may be made as apparent as pof- 
 iible. When clear day- light can be ob- 
 tained, it ought to be preferred; but when 
 this cannot be procured, one or more 
 candles fhould be ufed. 
 
 But, whatever may be the poiltion of 
 the part itfelf, and whether the patient 
 is to be placed on a bed or on a chair, 
 the furgeon ought always to be feated. 
 The operation may, no doubt, be done 
 while the furgeon is ftanding ; and it 
 is mod frequently indeed performed in 
 this manner : but it can never be done 
 either with fuch fleadinefs or neatnefs, as 
 when the operator is firmly feated on a 
 chair. 
 
 11. From the coats of veins being more 
 flaccid than thofe of arteries, and from the 
 blood not circulating with fuch rapidity 
 in the former as in the latter, an opening 
 made in one of thefe will feldom difcharge 
 blood freely, unlefs the vein be either cut 
 F 2 entirely 
 
$4 Of Blood'ldthig, Chap.Ilt. 
 
 entirely acrofs, which in general would be 
 productive of difagreeable confequences, 
 or unlefs the blood be prevented from re- 
 turning to the heart, by means of a liga- 
 ture placed between the heart and that part 
 of the vein in which the opening is to be 
 made. 
 
 The patient being properly feated, the 
 next ftep muft therefore be, by means of a 
 proper bandage fo to comprefs the vein in- 
 tended to be opened, as to prevent the blood 
 from returning to the heart ; and for the 
 fame reafon, an equal degree of preffure, 
 it is obvious, ought to be applied to all the 
 other veins of the part ; for, if this circum- 
 flance fliould not be attended to, the com- 
 munication preferved by the collateral cor- 
 refponding branches would render the 
 preilbre upon any one particular vein of 
 very little importance. But, independently 
 of its producing a more free difcharge of 
 blood than could be otherwife obtained, 
 this preflure upon the veins, bycaufingan 
 accumulation of their contents, tends to 
 bring them more evidently into view, and 
 
 confequentl/ 
 
Sea. I. Of Blood-ktthig. %^^ 
 
 confequently renders it eafier for the ope- 
 rator to affedl a proper opening than he 
 would otherwife find it. 
 
 Although compreflion, however, to a 
 certain extent, is neceiTary for this purpofe 
 of accumulating a quantity of blood in the 
 veins, and for afterwards difcharging it at 
 an opening made by the lancet, it is at the 
 fame time perfedlly evident that any con- 
 fiderable degree of prefFure, inflead of for- 
 warding thefe purpofes, mutl: ob(\ru(5ltherri 
 entirely ; for, if the prefFure intended to 
 be applied to the veins only, fhould acci- 
 dentally be carried fo far as to reft mate- 
 rially upon the arteries connected with 
 them, all farther accefs of blood to the veins 
 would be thereby cut off, fo that no eva- 
 cuation of importance could take place at 
 any opening to be made in them. When- 
 ever it is intended, therefore, to evacuate 
 blood in this manner, a good deal of 
 nicety is requifite in applying this preffure 
 upon the veins : It ought always to be car- 
 fled fo far as efFecflually to comprefs the 
 veins of the part, but never to fuch a length 
 
 ^ 3 ^J. 
 
^6 Of BlooJ-letilng. Chap. Ill, 
 
 as to obflrucl the circulation in the corre- 
 fponding arteries. When we fee that the 
 prefTure has the effedl of raifing the veins, 
 and if at the fame time the pulfation of 
 the artery is didindtly felt in the inferior 
 part of the member, we may then be cer- 
 tain that it is applied to a very proper de- 
 gree, and that it ought not to be carried 
 farther : For by the fwelling of the veins, 
 we are fure that they are fufficiently com- 
 prefTed ; and by the arteries continuing to 
 beat, it is evident that a continued flow of 
 blood may be expecfted. 
 
 111. The reflux of blood to the heart 
 being in this manner prevented, the next 
 point to be determined, is, the befl me- 
 thod of making an opening into the vein. 
 Different inf\ruments have been invented 
 for this purpofe ; but there are two only 
 which have been retained in ufe, and which 
 are all, therefore, that here require to be 
 mentioned. Thefe are, the Lancet and the 
 Phleme. This laft, on being placed im- 
 mediately on the part to be cur, is by means 
 pf a fpring flruck fuddenly into the vein^ 
 
 and 
 
Sea. I. Of Blood-letting, %j 
 
 and produces an opening of the exac^ fize 
 of the inftrument employed. 
 
 The phleme, in many parts of Germany, 
 has acquired ibme reputation, particularly 
 in taking blood from the jugular vein : But 
 there are various objedlions to this inftru- 
 ment, which will probably prevent it froni 
 ever coming into general ufe; and thefe 
 particularly are, that we are obliged, froin 
 the nature of the inftrunient, to regulate 
 the deepnefs to which it is to go, before it 
 is applied : Now we know well, that in 
 blood-letting this is a circumftance of which 
 we are never by any means certain ; for we 
 frequently, after the introduiflion of a lan- 
 cet, find it neceffary to go much deeper thaa 
 was at firft expeifled ; fo that when a 
 phleme is ufed, unlefs we employ one on 
 £very occafion of a length which cannot be 
 frequently required, we muft often meet 
 with difappointments. 
 
 But the mod material obje(flion to this 
 
 inftrument is, that where there are arteries 
 
 or other parts lying below the veins, and in 
 
 any danger of being hurt by the operation 
 
 F 4 of 
 
 x: 
 
8S Of Blood-letting, Chap.lII. 
 
 of blood-letting, the rifle is much greater 
 with the phleme than with the lancet: For 
 when the lancet is ufed, after the vein is once 
 opened, the orifice may be enlarged at plea- 
 fure without any additional riik, merely by 
 carrying the inftrument forward along the 
 courfe of the vein at the fame depth to 
 which it was at firft introduced; whereas 
 the phleme, as foon as it enters the vein,, 
 mufl: for certain pafs directly downwards a$ 
 far as its length will permit it to go; acir- 
 cumflance which adds greatly to' the rilk 
 of wounding the -parts underneath. 
 
 Independently of this too, by the ufe of 
 the lancet, we have it much more in our 
 power to command an orifice of a deter- 
 mined fize than \^hen the phleme is ufed: 
 So that without hefitation, we may vehture 
 to pronounce the phleme to be an inftru- 
 nient in no degree necefTary ; but for fuch 
 as incline to ufe it, themoft convenient form, 
 of one is reprefented in Plate III. fig. 2. 
 
 The manner of ufing the phleme is as 
 follows. The bandage for producing the 
 turgefcency of the veins being applied ia 
 
 the 
 

 J 
 
 Tiafe ly: 
 
 f^^./ 
 
 !l 
 
 fXr^^. 
 
 C.^>-^/. /Jr//f /ru/// 
 
gea.I. Of Blood-letting, 89 
 
 the manner already dire<fled, the point of 
 the inftrument A^ with the fpring properly 
 bent, mud be fo placed upon the part of 
 the vein to be opened, that an orifice of an 
 oblique diredlion may be made in it ou 
 the fpring B being let loofe. The fubfe- 
 quent management is the fame here as 
 when the lancet is ufed, and will be pre- 
 fently pointed out. 
 
 When it is determined to employ the 
 lancet, the form of the inftrument is evi- 
 dently the firft circumftance requiring our 
 attention; although we may here remark, 
 that this point is feldom fo particularly 
 attended to as it ought to be. 
 
 The form of lancet in ordinary ufe, as 
 reprefented in Plate IV. fig. 5. is an inftru- 
 ment which ought to be laid entirely afide. 
 For opening abfcefTes it is very well calcu- 
 lated, but for the operation of blood-letting 
 it ought never to be ufed. 
 
 The capital objeclion to this form of lan- 
 cet, is, that the broadnefs of its fhoulders 
 produces always a wound in the external 
 teguments of perhaps three times the fize 
 
 of 
 
9© Of Blood-letting, Chap. III. 
 
 of the opening made in the vein ; a cir- 
 cumftance which adds no advantage what- 
 ever to the operation : On the contrary, it 
 produces much unnecejTary pain in the 
 firft inftance; it renders it frequently a very 
 difficult matter to command a ftoppage of 
 the blood; and the wounds produced by 
 it are commonly fo extenfive as to render 
 them very liable to terminate in partial 
 fuppurations ; an occurrence which always 
 proves painful and difagreeable to the pa- 
 tient. 
 
 The fpear-pointed lancet, on the conr- 
 trary, as reprefented in Plate IV. fig. 3. and 
 4. is an inftrument in every refpecl well 
 calculated for the purpofe of vensefedlion. 
 From the acutenefij of its point, it enters the 
 teguments and vein with very little pain ; 
 which we may here obferve, is with many 
 patients a circumftance of no fmall impor- 
 tance: We are fure of making the opening 
 in the vein equal, or nearly fo, to the ori- 
 fice in the external teguments: And the 
 difcharge of blood produced by an opening 
 made with one of the lancets, is commonly 
 
Sea. I. Of Blood-letting. 91 
 
 put a ftop to with great eafe, immediately 
 on removing the Ugature upon the vein. 
 
 For thefe reafons, therefore, the fpear- 
 pointed lancet is highly preferable to every 
 other: And although, with timid pradi- 
 tioners, the acute point of this inftrument 
 may appear to require more dexterity in 
 ufing it than the broad-fhouldered lan- 
 cet; yet the difference in this refpecl is 
 fo inconfiderable, that very little expe- 
 rience muft, with every practitioner who 
 gives it a fair trial, very foon counterba- 
 lance all fuch objections. Indeed no 
 furgeon ought to be trufted in letting blood 
 with the one, whofe fteadinefs and dexte- 
 rity would be in any degree doubted with 
 the other. 
 
 IV. The form of lancet being thus fixed 
 upon, we come now to fpeak of the me- 
 thod of ufing it. The furgeon and patient 
 being both properly feated, and the ligature 
 having been applied for a fhort fpace of 
 time in order to produce fome degree of 
 fwelling in the veins, that vein is to be made 
 choice of, which, at the fame time that 
 
 it 
 
C^t Of Blood' let ting,. Chap. Ill, 
 
 it appears confpicuoufly enough, is found 
 to roll lefs than the others on being prefled 
 upon by the fingers. There are fome veins 
 which roll fo much, from being loofe and 
 unconneded with the cellular fubftance of 
 the part, that although they may rife fuffi- 
 ciently, yet are much worfe to operate up- 
 on than others which lie at a much greater 
 depth. That vein therefore is to be prefer- 
 red which not only rifes fo as to become 
 perfecflly evident, but which appears to be 
 connedled with fome degree of firmnefs to 
 the contiguous parts It is fcarcely thought 
 neceffary to obferve here, that when a vein 
 appears to be fo immediately connected 
 with a contiguous artery or tendon, as 
 evidently to produce fome rifle of wounds 
 ing thefe parts in the operation, if an- 
 other vein not liable to fuch hazard can 
 be procured, it ought undoubtedly to be 
 preferred. 
 
 Veins may lie diredly above both arteries 
 and tendons, and yet no manner of ri& be 
 incurred by opening them, provided the 
 .operator is fufficiently fteady and atten- 
 tive s 
 
Sec^. L Of Blood-letting, 9 j- 
 
 live; but it does now and then happen, 
 that veins are fo nearly and intimately 
 conne(5led with thcfe parts, as to render ic 
 hazardous even for the moft dexterous fur- 
 geon to attempt this operation. 
 
 The vein being at lafl made choice of, 
 the furgeon, if he is to ufe his right-hand 
 in the operation, takes a firm hold of the 
 member from whence the blood is to be 
 drawn, with his left, and, with the thumb 
 of the fame hand, he is now to make fuch 
 a degree of prefTure upon the vein, about 
 an inch and half below the ligature, as not 
 only to render the fkin and teguments 
 fomewhat tenfe, but at the fame time to in- 
 terrupt for a little all communication be- 
 tween the under part of the vein, and that 
 portion of it lying between the ligature and 
 the thumb placed as thus dire(5led. 
 
 The lancet being bent to fomewhat more 
 than right angles, the operator now takes ic 
 between the finger and thumb of his right- 
 hand; and, leaving at lead one half of 
 the blade uncovered, he reds his hand on 
 the middle finger, ring-finger, and little 
 3 finger, 
 
94 Of Blood-letting, Chap. III. 
 
 finger, all placed as conveniently as pof- 
 fible in the neighbourhood of the vein from 
 whence the blood is to be taken ; and ha- 
 ving puflied the point of the inftrument 
 freely through the flcin and teguments in- 
 to the vein, he now carries it forward in 
 an oblique direction, till the orifice is of 
 the fize he inclines to have it; taking care, 
 during the time of pufhing on the lancetj 
 that its point be kept in as flraight a di-^ 
 re6\ion as pofTible, for fear of dipping into 
 the parts below. 
 
 The inftrument is now to be withdrawn, 
 and the furgeon removing the thumb of 
 his left hand, is to allow the vein to empty 
 itfelf freely into the cups provided for the 
 purpofe. 
 
 It is here of importance to obferve, that, 
 during the time the blood is difcharging, 
 the member ought to be kept in exadly 
 the fame pofture it was in when the lancet 
 was firft introduced : Otherwife, the orifice 
 in the fl^in is apt to flip over the opening 
 in the vein ; a circumftance which always 
 proves inconvenient, and on fame occafions 
 
 produces 
 
Sea. I. ' Of Blood-letting, §^ 
 
 produces a good deal of trouble by the 
 blood from the vein Infinuating itfelf into 
 the furrounding cellular fubftance. 
 
 In taking hold of the lancet, we have di- 
 reded the fcales to form rather an acute 
 angle with the blade of the inftrument. It 
 will even anfvver when they are at right 
 angles ; but a farther feparation proves al- 
 ways troublefome, by throwing the fcales 
 too much back upon the operator's hand. 
 The length of inftrument left out from 
 between the finger and thumb is another 
 circumftance requiring our attention ; for 
 unlefs a fufficient quantity of it is left un- 
 covered, the operator cannot acl with free- 
 dom. In lancets of an ordinary length, 
 one half of the blade, as I have already 
 remarked, or very nearly that quantity, 
 ought always to be left out. 
 
 The entry of the lancet into the vein is 
 the next circumftance we have defired to 
 be attended to. By very little attention the 
 entrance of the inftrument into the vein 
 may be diftindly perceived ; for as foon as 
 its point has entered the cavity of the ^t^Q\^ 
 
 the 
 
Of Blood-letting. Chap. IIL 
 
 the refinance to its farther progrefs is evi- 
 dently found to be much diminiQied ; and 
 immediately on the opening being in any 
 degree enlarged, the blood begins to rufli 
 out, which is the cleared proof of the ope- 
 ration being fo far complete. On being 
 thus rendered fure that the lancet has got 
 into the vein, we have alfo defired that it 
 may be carried forward in an oblique di- 
 redlion, taking care to keep the point of 
 the inftrument in the fame degree of ela- 
 vation from the inftant it has pafTed fairly 
 through the coats of the vein ; and to this 
 part of the operation we would beg the 
 mod particular attention. To the wane 
 of neceffary caution in this matter, or ra- 
 ther to the improper regulations held forth 
 upon it by every writer on this fubjecfl, 
 much of the rifk attending this operation 
 ought to be attributed. 
 
 The propriety of an oblique diredion 
 for the courfe of the orifice is very obvious: 
 For, when made altogether longitudinal, 
 the fides of the wound are apt to fall im- 
 mediately together, fo as not to admit of a 
 free difcharge of blood j and, on the other 
 
 hand. 
 
Se6l. I. Of Blood-letting, 97 
 
 hand, when the vein is cut entirely acrofs, 
 troublefome confequences commonly en- 
 fue from the wound being very difficult to 
 heal: An orifice fomewhat oblique with re- 
 fpecfl to the courfe of the vein, is therefore 
 preferable to either. But the material cir- 
 cumftance to be kept in view is the direc- 
 tion of the point of the lancet after it has 
 got fairly into the vein. By almoft every 
 author who has written upon blood-letting, 
 as foon as the lancet is known to have got 
 into the vein, in order to extend the orifice 
 to a fufficient length, we are directed, very 
 properly, to carry the inftrument forward: 
 But in what manner are we defired to do 
 fo ? By raifing the heel of the lancet, as it 
 is termed, at the fame time that the point 
 and edge of it is in fome degree pufhed 
 forward, fo as to make the point of the in- 
 ftrument the centre of motion. 
 
 The reafon of this lad precaution is, 
 that the internal orifice of the vein may 
 not be farther extended upwards than 
 the external wound in the fkin and other 
 integuments j as ecchymofes, or efFuiions 
 
 Vol. I. G - of 
 
98 Of Blood'lettmg. Clia{». IIL 
 
 of blood into the cellular fubftance, have 
 with the broad-fhouldered lancet been 
 found frequently to occur from a contrary 
 management. But when the fpear-pointed 
 lancet is ufed, this is an occurrence which 
 may be always avoided; as, from the nar- 
 row point of the inftrument, it may with 
 fafety be carried on in the cavity of the vein 
 as far as is necefTary. The orifice produced 
 by it in the vein, muft, when the operation 
 is properly done, be always of very nearly 
 the fame extent as the external wound in 
 the teguments : And by the fame manage- 
 ment we avoid that capital ri£k which it is 
 evident muft always occur from an implicit 
 obedience to the diredlion alluded to ; for 
 one certain efFedl of railing the heel, or 
 back part of the lancet, is, that the point 
 of the inftrument muft in the fame pro- 
 portion be deprefled ; and the confequence 
 of lowering the point of the lancet, already 
 perhaps Hiding along the under fide of the 
 vein, muft at onee appear to be very ha- 
 zardous. For in fuch circumftances, if the 
 point of the inftrument be deprelTed, which 
 
 muft 
 
Sea. I. Of Blood-letting, , 99 
 
 mufl undoubtedly happen if the back pare 
 of it be elevated, it muft for certain pafs 
 through the back part of the vein; fo that 
 if either an artery, nerve, or tendon, lie con- 
 tiguous, they muft of neceflity be wound- 
 ed; and 1 am peirfecftly convinced, that this 
 caufc alone has frequently been the origin 
 both of wounded arteries, and of pricks in 
 the nerves and tendons. So that as the 
 hazard of the pradlice, whenever it is atten- 
 tively conlidered, muft at once appear evi- 
 dent, and as the fuppofed inconvenience 
 arifing from a contrary mode of operating 
 is efFedlually prevented by the ufe of the 
 fpear-pointed lancet, all fuch riflis there- 
 fore fliould be carefully avoided. 
 
 With refpe(fl to the fize of orifice in cafes 
 of blood-letting, this circumftance muft 
 at all times be determined by the nature 
 of the diforder for which the evacuation 
 is prefcribed. When a fudden lofs of a 
 confiderable quantity of blood is intended, 
 either with a view to produce a ftate of 
 fainting, or for any other reafon, a free 
 large orifice is abfolutely necefTary; but in 
 G 2 ordinary 
 
too Of Blood" letting. Chap. IlL 
 
 ordinary pradice, no necefTity occurs for 
 this. 
 
 In ufirig a fpear- pointed lancet, an ori- 
 fice of about an eighth part of an inch in 
 length will in general anfwer every pur- 
 pofe; but when a lancet with broad fhoul- 
 ders is ufed, an opening of twice that lize 
 is little enough ; for with fuch an inftrument 
 the orifice in the vein can feldom be above 
 half the extent of the external opening. 
 
 After withdrawing the lancet from the 
 orifice, we have diredled the thumb of the 
 left-hand to be removed from the place it 
 was macle to occupy. Many cireumftances 
 may appear to be related here with unne- 
 ceffary minutenefs, and this among others 
 may poilibly be confidered as one ; but in 
 an operation of importance, every parti- 
 cular requires much attention. Now, one 
 material ufe of the thumb placed below the 
 part where the lancet was directed to enter, 
 is, to keep the teguments and vein firm, {o 
 as to prevent the latter. from rolling. But 
 another advantage occurring from it is, that 
 by making a fafficient degree of prefi[ure 
 
 upon 
 
0ed. I, Of Blood-letting, 102 
 
 upon the vein, it thereby prevents any con- 
 fiderable quantity of blood from efcaping 
 between the time of removing the lancer, 
 and the application of one of the cups for 
 receiving the blood from the orifice in the 
 vein. During this period it frequently 
 happens, that a good deal of blood is dif- 
 charged, to the great annoyance both of the 
 patient, the operator, and byftanders ; a 
 jcircumftance which, with a little attention, 
 may be always effecftually prevented. 
 
 V, When the vein is properly cut, and 
 the orifice is made fufficiently large, it rare- 
 , ly occurs that any difficulty is experienced 
 in procuring all the blood that is wanted. 
 But it now and then happens otherwife, ei- 
 ther from the orifice of the fldn and other 
 parts having receded from the opening in 
 the vein, or from the patient having become 
 faintifh ; a fituation always unfavourable 
 to a free difcharge of blood. When this 
 laft circumftance occurs, a ftream of frefh 
 air ought to be admitted to the apartment, 
 wine or fome other cordial fhould be ad- 
 minifteredj and the patient ought to be laid 
 G 3 into 
 
102 Of Blood' leii'mg. Chap. III. 
 
 into a horizontal pofture. By thefe means 
 the faintifhnefs will in general be foon re- 
 moved ; but if ftill the blood fliould notflow 
 freely, the member ought to be put into all 
 the variety of poficions that caa probably 
 affift in bringing the opening of the fliin 
 and other teguments to corrcfpond with 
 that of the vein, which will foon be known 
 to have happened by the blood beginning 
 inftantly to flow. Throwing the mufcles 
 of the part into conflant adlion, by giving 
 the patient a cane or any other firm fub- , 
 jflance, to turn frequently round in his hand 
 when the operation is done in the arm, will 
 often anfwer in producing a conflant flow 
 of blood from a vein, when every other 
 means has failed : And laftly, when the 
 pulfe in the inferior part of the member 
 is felt very feeble, or efpecially if it can- 
 not be diilinguiflied at all, we may be 
 thereby rendered ceriain that the ligature 
 is too tight, and may in general have it in 
 our power to produce an immediate flow 
 of blood by removing the compreflion 
 
 thua 
 
Sedl. I. Of Blood-letting, 163 
 
 thus improperly made upon the arteries of 
 the part. 
 
 VI. A quantity of blood proportioned to 
 the circumftances of the diforder, being thus 
 difcharged, the prefFure upon the fuperior 
 part of the vein fhould be immediately re- 
 moved; and this being done, if the fpear- 
 pointed lancet has been ufed, all farther 
 difcharge of blood will in general (lop im- 
 mediately. The contrary, however, fome- 
 times occurs, and blood continues to flow 
 freely even after the ligature is removed. 
 When this is the cafe, the operator ought 
 to comprefs the vein both above and below 
 the oriticeby means of the finger and thumb 
 of one hand, fo as to prevent any farther 
 lofs of blood : And this being done, the limb 
 ought to be wafhed and entirely cleared of 
 any blood that may have fallen upon it; and 
 the orifice being alfo cleared of every par- 
 ticle of blood, the fides of it fhould be laid 
 as exadlly together as pofilble, and a piece of 
 what is named court- plafter, or any other, 
 that is fufficiently adhefive, being {^o ap- 
 plied as to retain them, it v/ill feldom hapf 
 Q 4 ' " pen , 
 
104 Of Blood-letting. Chap. IIL 
 
 pen that any kind of bandage is neceflary : 
 But when the blood has ilTued with un- 
 common violence during the operation, 
 and has been difBcuIt to command after 
 the removal of the ligature, in fuch in- 
 ftances it will be prudent to apply a fmall 
 comprefs of linen over the plafter, and to 
 -fecure the whole with a linen roller pro- 
 perly applied round the member. 
 
 Before applying the plafter, we have di- 
 rected the orifice to be perfedly cleared of 
 every particle of blood ; and this, it may 
 be obferved, is a circumftance of more im* 
 portance than is commonly imagined; for, 
 by not attending particularly to this point, 
 and from want of e3va(5lnefs in clofing the 
 lips of the orifice, painful fwellings and 
 confequent fuppurations are often induced, 
 which a very little attention would have 
 eafily prevented. In every inftance when 
 the operation is properly done, the wound 
 ought to heal by what furgeons call the 
 f irft Intention, that is, by the parts adhe- 
 ring to one another without the formation 
 of matter ; but this can feldom happen if 
 the lips of the for© have not been very neat- 
 
Se(5l. I. Of Bhod'kttmg^ 1©^ 
 
 ly laid together after all the blood has beeu 
 perfedlly cleared away. 
 
 Another argument of importance, tooj 
 occurs for neatnefs in this matter. Among 
 other troublefome confequences ariling 
 now and then from blood-letting, inflam- 
 mation produced in the cavity of the vein 
 has in fome inftances been known to occa- 
 fion much mifchief ; and as nothing tends 
 more to produce it than the admiflion of 
 air to the part, by the orifice in the vein 
 jiot being properly clofed, this circumftance 
 of itfelf ftrongly points out the propriety 
 of the caution here given : For although 
 fuch inflammatory afl'edlions in the inter- 
 nal furfaces of veins are not by any means 
 to be confidered as frequent, yet it is cer- 
 tain they do now and then occur ; and as 
 the confequences ariiing from them, efpe- 
 cially if fuppuration is induced, mud com- 
 monly terminate fatally, they ought cer- 
 tainly, by every means in our power, to 
 be ftrid^ly guarded againft. ' 
 
 VII. We come now to fpeak of fome 
 fypublefome confequences which on fome 
 
 occafions 
 
Io6 Of Blood-letting, Chap. HI. 
 
 occalions are found to occur from blood- 
 letting, and which every operator ought tQ 
 be as much as pofTible prepared to remedy. 
 The mod material of thefe are, fmall tu- 
 mors occafioned by efFufions of blood from 
 the orifice of the vein into the furround- 
 ing cellular fubflance ; wounds of the ar- 
 tery lying contiguous to the vein ; pricks of 
 the nerves and tendons ; and laftly, inflam- 
 mation, induced in the internal cavity of 
 the vein, as we have juft now mentioned. 
 Thefe we fliall now, under feparate heads, 
 proceed to treat of particularly *. 
 
 SEC- 
 
 * Among other reafons which we have given for 
 preferring a fpear-pointed lancet, it was obferved, that 
 by means of it the operation of blood-letting is attend- 
 ed with much lefs pain than when the broad- Ihouldered 
 lancet is ufed : And the prevention of pain is a mat- 
 ter of fuch importance, that nothing ftiould be omitted 
 that can in any degree contribute to it. 
 
 In every operation it is of much confequence to have 
 all the neceffary inftruments in the moft complete or- 
 der i but in no inftance is it of fuch importance to 
 attend to this circumftance as in blood-letting. Well- 
 tempered lancets will no doubt anfwer tolerably wellj 
 even after they have been frequently ufed ; infomuch 
 
 that 
 
Scd. II. Of Blood' Idting, l o 7 
 
 SECTION II. 
 
 Of a Thrombus^ or Kcchymofts. 
 
 TTTE have already defired, that in the 
 operation of blood-letting, the mem- 
 ber fhould be retained in the very fame 
 pofture it was in when the lancet was in- 
 troduced, till the whole quantity of blood 
 intended to be taken is evacuated. When 
 this dire(flion is not duly attended to, ic 
 commonly happens, that a fmall tumor 
 is raifed immediately above the ori- 
 fice 
 
 that I have heard even well-employed furgeons aflert, 
 th^t they have ufed one or two lancets only during the 
 courfe of rnany years pradlice, without ever having 
 them touched by a cutler. But it is very certain, that 
 every time a lancet is ufed, it mull be injured more or 
 lefs \ fo that, as the prevention of pain is with moft 
 patients a matter of no fmail confequence, I think it 
 ought to be laid down as a fixed rule never to ufe the 
 fame lancet twice, without putting it into the hands 
 of a cutler. This I have long been in the pradlice of 
 doing, not only with lancets, but with every cutting 
 inftrument ; and the trouble and expence attending it 
 is very inconfiderable, v/hen compared with the ad' 
 yantages refulting fjom it. 
 
loS Of Blood-letting. Chap.IIL 
 
 fice in the vein, by the blood infinuating 
 itfelf into the cellular fubftance of the 
 neighbouring parts. Such a tumor, when 
 round and fmall, is termed a Throm- 
 bus ; and when more difFufed, an Ecchy- 
 mofis. 
 
 Immediately on the appearance of fuch 
 fwellings, the ligature ought to be removed 
 from the fuperior part of the vein ; and the 
 member being brought into that pofture 
 which it was in when the lancet was firfl 
 introduced, the ligature may be again re- 
 newed ; and it will thus be frequently found 
 that a free return of blood will be induced, 
 which commonly carries off the fwelling 
 altogether, or at lead prevents it from pro- 
 ducing any further obftruclion to the dii^ 
 charge of blood. But it does now and then 
 happen, that thefe fwellings come at once 
 to fuch a fize, as entirely to preclude every 
 poffibility of finifhing the operation at the 
 orifice firfl made in the vein. Even here, 
 however, the ligature ought to be imme- 
 diately removed, as the mod effectual me- 
 thod of preventing an increafe of the tu- 
 mor. 
 
Sed. tl. Of Blood-letting, 369 
 
 mor. By continuing the bandage on the 
 vein, the blood ftill continues to be forced 
 in great quantities into the furrounding 
 cellular fubftance ; and by the fame means 
 fuch fwellings are induced, as now and 
 then give a great deal of trouble, which by 
 a contrary management might eafily have 
 been prevented from coming to any con- 
 fiderable height. 
 
 In fuch occurrences, as it is in vain to 
 expe(5l any confiderable quantity of blood 
 from the orifice firft made, the next ftep to 
 be taken, is, to finifh the operation, not by 
 another opening in the fame vein, which 
 in fuch circumilances would feldom be 
 found to bleed freely, but in any other 
 that li^s moil convenient. 
 
 When tumors of this kind do not arrive 
 at any great fize, very little is necefTary to 
 be done for their difperlion, as the eifufed 
 blood is commonly foon abforbed. When 
 it is found necefTary, however, to have re- 
 courfe to difcutient remedies, thofe of the 
 aflringent kind are by far the moft ef- 
 fedual ; and of this clafs brandy or any 
 .'? other 
 
II®' of Blood'httkg, Chap. III. 
 
 other ardent fpirits are perhaps as ufeful 
 as any. ComprefTes wet in a weak folu- 
 tion of crude fal ammoniac in vinegar, 
 and applied wit'i a very moderate degree 
 of prefTure, have llkewife been found very 
 efFeclual in difcuffing fuch fwellings. 
 
 Inftances, however, do now and then 
 occur, though by no means very frequently, 
 of the blood collecfled in fwellings of this 
 nature being in too great quantities to be 
 all abforbed: and when this happens to 
 be the cafe, as no good fuppuration can be 
 induced where there is nothing but red 
 blood contained in the tumor, it ought to 
 be immediately laid open as foon as there 
 is reafon to fuppofe that no farther dimi- 
 nution of fize will probably occur from 
 abforption. This being done, and the coa- 
 gulated blood being evacuated, the fore falls 
 to be treated like any ordinary wound. 
 
 But occurrences of this nature, are in 
 general of very little importance when 
 compared with other accidents which now 
 and then proceed from blood-letting. The 
 
 fira 
 
Sedl. 111. Of Blood-kuing, m 
 
 firft of thefe we are to treat of are wounds 
 of arteries. 
 
 SECTION III. 
 
 Of Wounds of the Arteries, 
 
 JN the fmaller arteries, as for inftance in 
 any branch of the temporal artery^ 
 openings maybe made without much rilkj 
 but we know from long and repeated ex- 
 perience, that wounds in the larger arteries 
 often prove hazardous, and very feldom 
 heal without a great deal of trouble. 
 
 When in blood-letting we have reafon 
 to fufpedl that an artery has been wounded 
 through the orifice made in the vein, and 
 that blood is difcharging at the fame ori- 
 fice both from the artery and the vein, ic 
 becomes a matter of importance for an 
 operator to know with precifion whether ic 
 is fo or not. There is only one method by 
 which a complete degree of certainty can 
 be obtained on this point ; and it is this ; 
 
 When the blood is difcharged from the 
 
 vein only, if adegreeof prefTurebe applied 
 
 3 both 
 
i 1 2 Of Blood' letting. Chap. III. 
 
 both Immediately above and below the 
 orifice fufficient for compreffing the fides 
 of the vein together, all farther evacuation 
 of blood fhould inftantly flop, even though 
 the prefiTure is not fo confiderable as to 
 affed the artery below ; but on the con- 
 trary, if part of the blood be thrown out 
 from the wounded artery, this preffure 
 upon the vein, inftead of putting a flop to 
 the difcharge, fhould rather tend to make 
 it more confiderable. When at the fame 
 time the blood is difcharged per faltuna 
 this will no doubt ferve as a corroberating 
 circumftance: But this teft of itfelf, we may 
 remark, is by no means fo decifive as is 
 commonly imagined ; for, an orifice made 
 in a vein lying diredlly above and imme- 
 diately contiguous to a confiderable artery, 
 receives the influence of the arterial pulfa- 
 tion to fuch a degree, as to difcharge blood 
 very nearly in the fame manner as if the 
 artery itfelf was cut. No other proof 
 however, is necefiTary of the artery being 
 wounded, than the one we have already 
 mentioned ; for, if after the vein is tho- 
 roughly 
 
Bed, lit Of Blood-letting: 1 1 3 
 
 i'oughly comprefled both above and below 
 the orifice, blood flill continues to be 
 difcharged in great quantities and with 
 any confiderable forces o^v fufpicions of 
 the artery being wounded are then reduced 
 to the utmofl degree of certainty. 
 
 Allowing this to be the cafe, that in fuch 
 circumftances we are rendered certain of 
 the lancet having pierced the artery, what 
 remedy ought we to have recourfe to? Not 
 the means ufually advifed, but the very 
 reverfe. 
 
 In ijl fuch occiirrences, we are con« 
 ftantly direded to tie up the part with as 
 much firmnefs as poflible, in the firll: place 
 with different compreffes placed over the 
 orifice of the vein ; and lead thefe fhould 
 not produce a fufficient degree of preffure, 
 a piece of money or other hard fubftance 
 is defired to be added, and the whole to be 
 fecured with a roller very tightly applied. 
 But what effect ought we reafonably to 
 expecl from much preiTure applied in this 
 manner ? We cannot fuppofe it was ever 
 intended that any preffure cf this kind 
 
 ¥oL,I. H jQioiiB 
 
114 Of Blood-letting, Chap. Ill, 
 
 ftiould be fo confiderable as to comprefs 
 the artery itfelf ; for by that means when 
 the principal artery of a part is wounded, 
 a total (top would be put to the circulation 
 in the whole limb: And if the prefTure, on 
 the contrary, is to be appUed in fuch a 
 degree as to comprefs the fides of the veins 
 only, one certain effedl of this mufl be, to 
 occafion a confiderable refiftance to the flow 
 of blood from the artery ; and that fluid 
 being thus obftrudedin its natural courfe, 
 will necelTarily be much more readily ef- 
 fufed at the opening in the artery, than if 
 the veins had been all left free and pervi- 
 ous to receive and tranfmit it. 
 
 In all fuch cafes, therefore, inftead of 
 applying much prefigure, we ought to at- 
 tempt every means of relaxing the veins to 
 the utmoft ; and in order to command 
 the blood, the lips of the wound fliould be 
 laid together, .and retained by ftraps of 
 adhefive plafter only, without any ban- 
 dage whatever. And as there is not a 
 more effectual method of relaxing the 
 fyftem at large, and the vafcular fyfl:em 
 
 m 
 
Sea. III. Of Blood-letting, ii^ 
 
 in particular, than^by difcharging large 
 quantities of blood very quickly, fo fooii 
 as it is known that an artery has been ac- 
 cidentally opened, it ought to be imme- 
 diately determined to evacuate by the ori- 
 fice newly made, as much blood as the 
 patient can eafily bear to lofe. ^ By thefe 
 means, and by enjoining flritfl attention 
 to reft of body, in order to prevent as 
 much as pofTible the undue adion of the 
 airterial fyftem, and by keeping the body 
 cool, with the ufe of gentle purgatives, a 
 low diet, and farther blood-lettings when 
 neceffary, there may always be at leaft fome 
 chance of fuch wounds in arteries being 
 brought to reunite : Whereas a contrary 
 management, in which much prefTure upon 
 the veins is advifed, muft univerf^ly do 
 mifchief, by forcing the artery to empty 
 itfclf at the only pafTage the blood in fuch 
 circumftances can be difcharged at, viz. 
 the opening newly made by the lancet ; and 
 by fuch treatment many aneurifmal fwel- 
 lings, I am confident, have been produced, 
 H 2 which 
 
1 1 6 Of Blood-letting. Chap. IIL 
 
 •which by the managgment now pointed 
 out might eafily have been prevented. 
 
 In cafes of wounded arteries, however, it 
 will frequently happen, that no treatment 
 whatever will fucceed ; the orifice in the 
 artery will not reunite, and blood in confi- 
 derable quantities is effufed into the conti- 
 guous parts. Even in this (late of the com- 
 plaint, ftrong prelTure is advifed, with a 
 view to diffipate the tumor : But unlefs 
 the fwelling is of a very foft nature, and 
 unlefs the blood contained in it dill remains 
 in a ftate of fluidity, no prefTure whatever 
 can have any influence in difcuffing itj 
 for, whenever the accumulated blood has 
 acquired any moderate degree of firmnefst 
 we cannot fuppofe that prelfure will have 
 any effetfl in driving it back by the paffage 
 from whence it originally came. Nor does 
 it appear, that in fuch circumftances, com- 
 preiTion is of any ufe in forwarding the 
 abforption of extravafated blood. From 
 theory alone we might readily be induced 
 to draw this conclufion ; but in fa6l we do 
 not know a fingle inf^ance in which pref- 
 
 fure 
 
Sed. III. Of Blood- letting, iry 
 
 fure In fuch cafes appeared to be produc- 
 tive of any advantage. 
 
 There is indeed a particular fpecies of 
 fwelling, which now and then occ^irs on an 
 artery being in this manner wounded by a 
 Jancet that has previoufly pafTed through a 
 neighbouring vein, and in which mode- 
 rate prelTure has proved ferviceable. When 
 an artery thus wounded, lies quite conti- 
 guous to the correfponding vein, the open- 
 ing between the two vefTels on fome occa- 
 iions continues pervious after the external 
 orifice in the vein is clofed, fo as to produce 
 a dire(5l communication between the one 
 and the other ; and the vein in this man- 
 ner receiving the full force of the arterial 
 pulfation, at the fame time that its coats 
 are not pofleffed of a firmnefs fufficient to 
 refift it, a fwelling of the vein comes of 
 courfe to be produced. In all fuch inftances, 
 moderate prefFure, we may readily fuppofe, 
 muft be of very great ufe, by ferving as 
 a fupport to the diftended vein, and by 
 thus preventing any farther increafe of 
 its bulk ; but in no other fwelling arifing 
 _H 3 from 
 
ji8 Of Blood-letting. Chap. HI. 
 
 from blood eflFufed from an artery caa 
 prefTure be of any ufe; on the contrary 
 indeed, for the reafons already enumerated, 
 there is great caufe for fufpeding that it 
 has frequently done much mifchief. When 
 we are rendered quite certain that an ar- 
 tery has been opened, and that the tumor 
 produced by it is owing to blood colle6led 
 in the cellular membrane around it, if keep- 
 ing the limb in an eafy relaxed pofture, and 
 the veins pertecSlly free from prefTure, to- 
 gether with the other means formerly 
 pointed out, do not prevent a farther in- 
 creale of the fwelling, no other mode of 
 treatment with which we are acquainted 
 will have much influence. 
 
 The tumor ilill continuing, by the com- 
 munication between it and the artery be- 
 ing conftantly kept up, and none of the 
 means employed for its difperfion having 
 any influence, the diforder in that flate 
 is to be confidered as forming a fpecies of 
 fmeurifm, an ailment of which we will 
 treat more particularly afterwards. 
 
Sed. IV. Of Blood-letting, 1 19 
 
 SECTION IV. 
 
 Of Wounds or F ricks in the Nervss and Tendons, 
 
 npHE diforder we have now been de- 
 fcribing, 'uiz. wounds of the arteries, 
 as well as fimilar afFeclions of the tendons, 
 ought never to happen in the hands of a 
 furgeon who pretends to any tolerable de- 
 gree of fteadinefs ; for, as the arteries and 
 tendons are both parts which previous to 
 the operation may be eadly diftinguiihed 
 by the finger, fo as that their ficuation may 
 be afcertained with exactnefs, it mufl al- 
 ways be the fault of the furgeon, if the 
 point of his lancet is not fo directed as to 
 avoid them. One principal caufe of fach 
 accidents occurring in blood-letting, is, as 
 we have already Ihown, the ordinary prac- 
 tice of depreffing the point of the lancet, 
 after it has entered the cavity of the vein. 
 This, however, we have demonftrated to 
 be always unnecelTary, ■ and in many in- 
 ftances to be producflive of very pernici'- 
 ous efiPeds. But although, by proper at- 
 H 4 tentigii 
 
120 Of Blood-letting, Chap. HI. 
 
 |:entIon to this part of the operation, we 
 may always with certainty avoid the ar- 
 teries and tendons; yet it maybe faid, that 
 the nerves, which in general are fo fmall 
 as not to be previoufly diftinguifhed, run 
 at all times a great rilli of being wounded, 
 and that the accidents which now and 
 then occur from wounded nerves, are well 
 known to be produdive of as dreadful con- 
 fequpnces as have ever fucceeded to the ope- 
 ration of blood-letting. 
 
 But although the nerves from the fmall- 
 nefs of their fize cannot previoufly be di- 
 iHnguifned by the fingers; yet, if fufficient 
 attention be given to the diredtion of the 
 point of the lancet, fo as to avoid with 
 certainty carrying the inflrument through 
 the back part of the vein, the fame means 
 which tend to fecure the arteries and ten- 
 dons, will with almofl: equal furenefs prove 
 a fafeguard to the nerves : For, if the ope- 
 rator enters his lancet, as he ought always 
 to do, on the fuperior part of the vein, an4 
 if he does not cut the vein entirely acrofs 
 by pufliing the lancet throngh tp the op- 
 
3ea. IV. of Bhod'ktting. nt 
 
 pofite fide of it, he can never run any rifk 
 of wounding che contiguous nerves : for 
 thefe, though they run fo near to the 
 veins, yet either He immediately below 
 them, or at leaft are iituated fo far down 
 upon their fides as to be out of all rifk of 
 being wounded, if the lancet is made, to 
 enter where it ought to do; and it muft 
 always be the furgeon's fault if the inftru- 
 ment is pufhed out at the oppolite fide 
 of a vein. I may venture to alTert, that 
 no inconvenience of this kind ever hap- 
 pens, from the wound made by a lancet 
 in entering the anterior part of a vein : It 
 is always on the oppofite fide of the vein 
 that any mifchief of this kind is produced, 
 when the lancet, as we have already ob- 
 ferved, is puflied entirely through; which 
 it never ought to be, and which every 
 furgeon ought to have fteadinefs enough 
 to prevent. 
 
 But although a very ordinary degree of 
 caution would eafily prevent every occur- 
 rence of this nature; and although, when 
 accidents of this kind do happen, the fur-- 
 
 geoa 
 
122 Of Blood-letting, Chap, III, 
 
 geon is almofl: in every inftance to blame; 
 yet experience has on different occafions 
 evinced, that, either from the want of at-^ 
 tention, or from the operator not being 
 poffefTed of a fufEcient degree of fleadinefs, 
 however eafily fuch inconveniences ought 
 to be prevented, yet ft ill they do frequent- 
 ly occur. Nerves, and even tendons, are 
 fometimes pricked ; and the dreadful train 
 of fymptoms which fuch accidents com- 
 monly produce is almoft inevitable. 
 
 It fometimes happens immediately on 
 the introdu(5lion of the lancet, that the pa- 
 tient complains of a moft exquifite degree 
 of pain ; and when this occurs, we may reft 
 affured that either a nerve or tendon has 
 been wounded. On fome occafions, by 
 proper management, fuch as evacuating a 
 confiderable quantity of blood at the ori- 
 fice newly made, by keeping the part at 
 perfedl reft, and preferving the patient in 
 as cool a ftate as pofiible, the pain at firft 
 complained of will gradually abate, and at 
 laft go off entirely without any bad confe- 
 quence whetever. 
 
 At 
 
Sea. IV, Of Blood-letting, 123 
 
 ' At other times, however, this pain which 
 occurs inftantaneoufly on the introdudion 
 of the lancet, inflead of abating, begins fooa 
 to increafe; a fuilnefs, or fmall degree of 
 fweliing, takes place in the parts contiguous 
 to the wound ; the lips of the fore become 
 fomewhat hard and inflamed ; and in the 
 courfe of about twenty-four hours from 
 the operation, a thin watery ferum begins 
 to be difcharged at the orifice. 
 
 If, by the means employed, relief is not 
 foon obtained, thefe fymptoms generally 
 continue in nearly the fame (late, for two, 
 or perhaps three days longer. At this time 
 the violent pain which at firft took place be- 
 comes ftiil more diftrefling; but inl\ead of 
 being Iharp and acute as before, it is now 
 attended with the fenfatipn of a burning 
 heat, which ftill goes on to increafe, and 
 proves during the whole courfe of the ail- 
 ment a fource of conflant diftrefs to the 
 patient. The fuilnefs and hardnefs in the 
 lips of the wound begin to increafe, and 
 |:he fweliing in the neighbouring parts 
 gradually extends over the whole member; 
 
 from 
 
12^ Of Blood4dting. Chap. Ill, 
 
 from tlie foot upwards over the thigh, 
 when the operation has been done in the 
 lower extremity; and from the elbow 
 down the fore- arm, and along the hume- 
 rus over to the perioral mufcle and other 
 contiguous parts, when the accident has 
 occurred at the ufual place of blood-letting 
 in the arm. 
 
 The parts at lafl become exceedingly 
 tenfe and hard ; an eryfipelatous inflam- 
 matory colour frequently appears over the 
 whole member ; the pulfe by this time has 
 generally become very hard and quick; 
 the pain is now intenfe, the patient ex- 
 ceedingly reftlefs ; twitchings of the ten- 
 dons occur to a greater or lelFer degree ; 
 on fome occafions, a locked jaw and other 
 convulfive affe6lions fupervene; and, all 
 thefe fymptoms continuing to increafe, it 
 mofl frequently happens, that the fuffer- 
 ings of the unfortunate patient are termi« 
 nated by death only. 
 
 Blood-letting, from being fo very gene^^ 
 rally pradifed, may by many be confi- 
 dered as an operation by no means either 
 
 fo 
 
&a.lV. Of Blood-kiting. i'2| 
 
 fo difficult in execution, or fo dreadful in 
 its confequences, as is here repreiented. 
 Such inftances indeed are not to be ccnfi- 
 dered as frequent occurrences ; but they 
 happen often enough to convince us of the 
 neceffity of very great caution in this ope- 
 ration. In the courfe of my experience I 
 have known feveral inftances where the 
 confequences of blood-letting have proved 
 fatal, and the dreadful train of fymptoms 
 we have already enumerated uniformly 
 occurred in all of them. 
 
 Different opinions have prevailed re- 
 fpecSling the caufe of thefe fymptoms : By 
 ibme they have been imputed to wounds 
 of the tendons ; and by others the tendons 
 are fuppofed to be fo entirely deftitute of 
 fenfibiiity, as to be quite incapable of pro- 
 ducing fo much diftrefs j fo that wounds 
 of the nerves they confider in all fuch oc- 
 cafions as the true caufe of the various 
 fymptoms we have mentioned. 
 
 On one or the other of thefe fuppofi- 
 tions the various phenomena which occur 
 in this diforder have been explained, till 
 
 a 
 
i26 Of BIoGd'kttlng, Chap, lit, 
 
 a different opinion was at lafl fuggefted 
 by the ingenious Mr John Hunter of 
 London. Mr Hunter fuppoles, that all 
 the fymptoms thus induced by the opera- 
 tion of blood-letting, may be more rea- 
 dily accounted for, from an inflamed 
 ftace of the internal furface of the vein, 
 than from any other caufe. Such a (late 
 of the vein he has ofcen traced in horfes 
 that have died of fuch fymptoms from 
 venacfedfion, where the internal coat of 
 the vein was always found much in- 
 flamed, not only in the neighbourhood of 
 the part where the orifice was made; buc 
 on fome occaiions the inflammation ex- 
 tended along the whole courfeof the vein, 
 and feemed at laft to reach the heart it- 
 felf. Some inftances too have occurred, 
 of the fame appearances in the human 
 body, v/here the veins after death were 
 found in a flate of high inflammation. 
 And on other occaflons, inflammation 
 having in this manner been once excited, 
 has been known to terminate in fuppu- 
 ration ; and the matter thus produced, 
 I being. 
 
Se<5l. IV. Of Blood-letting, 1 2 J 
 
 being in the courfe of circulation carried 
 to the heart, Mr Hunter fuppofes that in 
 fuch cafes death may have been induced 
 by that caufe alone. 
 
 There can be no reafon to doubt the 
 fadl held forth by Mr Hunter, that in fuch 
 inftances, the vein in which the orifice 
 has been made, has frequently after death 
 been found greatly inflamed : But how- 
 ever ingenious his arguments may be, for 
 concluding that this ftate of the vein is the 
 original caufe of all the bad fymptoms 
 enumerated ; and although we muft allow, 
 that fuch an inflammatory afFedlion of a 
 vein muft have a coniiderable influence in 
 aggravating the various fymptoms previ- 
 oufly induced by other caufes; yet I think 
 we may very fairly conclude, that it could 
 not probably in any one inftance be able to 
 account in a fatisfadory manner for their 
 firft produdion. 
 
 In all the inftances of this dreadful com- 
 plaint which I have had an opportunity 
 of feeing, the patient at the very inftant of 
 the operation felt a very unufual degree 
 
 of 
 
*2S Of Bloodletting. Cliap.llL 
 
 of pain. In fome cafes, the violence of the 
 pain was almoft infupporcable. Now this 
 wc can never fuppofe to have been produced 
 by the mere puncture of a vein ; for akho' 
 the coats of veins are not perhaps entirely 
 deftitute of feeling, yet we know well, that 
 they ate not endowed with fuch a degree of 
 fenfibility as to render it probable fuch in- 
 tenfe pain could ever be induced by their 
 being pundured in any way whatever. 
 This inflamed flate of the veins therefore, 
 as detected by Mr Hunter after death, muft 
 be confidered rather as being produced by,- 
 than as being productive of, fuch affec- 
 tions ; and that fuch ailments fliould fre- 
 quently produce an inflammation of the 
 contiguous veins, is a very probable con- 
 jecture. In the courfe of about forty-eight 
 hours from the operation, when the febrile 
 fymptoms are juft commencing, fuch a 
 degree of hardnefs and evident inflam- 
 mation is induced over all the parts con- 
 tiguous to the orifice, that it would be 
 furprifing indeed, if the vein, which is 
 thus perhaps entirely furrounded with' 
 
 part* 
 
Sea* IV. Of Blood-letting. 129 
 
 parts highly inflamed, fliould not be in- 
 flamed likewife. 
 
 We fliall therefore proceed upon the 
 fuppofition of this inflamed fl:at:e of the 
 veins being a confequence, rather than the 
 caiife, of fuch ailments ; and of courfe we 
 now revert to one or other of the opinions 
 long ago adopted on this fabjetfl, that all 
 the train of bad fymptoms found on fome 
 occafions to fucceed to vensefedion, pro- 
 ceed either from the wound of a nerve or 
 of a tendon. 
 
 That a partial wound of a nerve will 
 now and then produce very diflrefling 
 fymptoms, no practitioner will deny : But 
 it has been attempted to be fliown, as we 
 have already remarked, that tendons are 
 almoft totally defl.itute of feniibiiity ; and 
 it has therefore been fuppofed, that their 
 being wounded, can never account for the 
 various fymptoms known to occur in fuch 
 cafes. 
 
 There is great reafon, however, to think, 
 that in different inftances the fame train of 
 fymptoms have been induced by different 
 
 Vol. I, I caufes ; 
 
i^o Of Blood-letting, Chap. 11, 
 
 caufes ; that in one inftance a wounded 
 nerve, and in others pricks of the tendons, 
 have given rife to them. Being decidedly 
 of this opinion myfelf, I think every perfon 
 mufl be fo, who has paid much attention, 
 to the fubjecft ; but as the fame method of 
 treatment proves equally applicable, whe- 
 ther the difeafe has originated from the 
 wound of a nerve or of .a tendon, we do 
 not think it neceflary to enter here into a 
 more minute difcufTion of the queftion. 
 Having already in a former fedion fhown 
 how fuch accidents may be almoft always 
 avoided, v/e fhall now proceed to confider 
 the means befl calculated for preventing 
 the fymptoms coming to a great height, 
 when it is difcovered that either from in- 
 advertence or any other caufe the mifchief 
 has adlually happened. 
 
 Whenever a patient at the time of the 
 operation complains of a very exquifice 
 degree of pain, we may always be certain 
 that fome parts have been wounded which 
 ought not to have been touched. When 
 this unfortunately happens, if proper atten- 
 tion 
 
Bedl. IVi Cf Bhod-letttngi iji 
 
 tion be given immediately, miich itiay ht 
 done to obviate the acceflion of thofe fymp- 
 toms which fuch a caufe will otherwife 
 certainly induce. 
 
 In order therefore to prevent as much as 
 poflible the confequent inflammation and 
 other fymptoms which ufually enfue, a 
 confiderable quantity of blood fhould be 
 immediately difcharged at the orifice juft 
 made ; the limb, for feveral days at leafti 
 ought to be kept in a ftate of perfedl reft^ 
 care being at the fame time taken that the 
 inufcles of the part be all preferved in as 
 telaxed a ftate as poflible ; the patient 
 fhould be kept cool ; on a low diet ; and^ 
 if neeeflfaryj gentle laxatives ought to be 
 adminiftered. 
 
 By fuch management alone, the fatal 
 fymptoms we have enumerated may fre- 
 quently be prevented ; and when they do 
 occur in cafes where the above precau- 
 tions have not been taken, they may he 
 confidered to be as much the confequence 
 of negligence in the fubfequent treatment^ 
 I 2 as 
 
132 Of Blood' let ting. Chap. Ill 
 
 as of any thing peculiarly bad in the na- 
 ture of the original accident. 
 
 When notwithftanding, however, of the 
 means recommended, the fymptoms, in- 
 flead of diminifliing, rather become more 
 violent, if the lips of the orifice turn hard 
 and more inflamed, if the pain becomes 
 more confiderable, and efpecially if the 
 fwelling begins to fpread, other remedies 
 come then to be indicated. In this ftate 
 of the complaint, topical blood-letting, by 
 means of leeches applied as near as pofTible 
 to the lips of the wound, frequently affords 
 much relief; and when the pulfe is full and 
 quick, it even becomes neceflary to eva- 
 cuate large quantities of blood by open- 
 ing a vein in fome other part. 
 
 The external applications ufually em- 
 ployed in this ftate of the complaint, are, 
 warm emollient fomentations and poultices j 
 and in fimilar afFedlions of other parts no 
 remedies with which we are acquainted 
 would probably be found more fuccefsful ; 
 for as warm fomentations and cataplafms 
 tend in general very powerfully to promote 
 
 the 
 
Sedl. IV. Of Blood' letting, 133 
 
 the formation of pus, and as nothing would 
 fo certainly relieve the fymptoms which 
 ufually occur here as a free fuppuration, 
 applications of this nature were made there- 
 fore with fome apparent propriety : But 
 from all the experience I have had in af- 
 fedlions of this kind fucceeding to blood- 
 letting, I am now perfectly convinced, 
 that little or no advantage is ever to be ex- 
 pe6led from remedies of this clafs. On the 
 i^ea of being able to induce a free and 
 kindly fuppuration on the wound, and ha- 
 ying great reafon to think, from its effedls 
 in fimilar cafes, that all the fymptoms 
 would be thereby rendered more mild, I 
 muft own that in feveral cafes I went into 
 the ufe of applications of this kind to the 
 greateft pofTible degree. Unfortunately, 
 however, the advantages refulting from 
 them never anfwered my expedations ; fo 
 that at lad I was induced to make trial of 
 a very different fet of remedies. 
 
 Although, at the time of thus ufing ap- 
 plications of the warm emollient kind, I 
 4id not attend particularly to the caufe of 
 I 3 thei^ 
 
X34 Of Blood-letting, Chap. Ill, 
 
 their failure, yet 1 now think that this cir^ 
 Gumftance may be very eafily accounted 
 for. The pares here principally concerned 
 being almcft entirely membranous, and 
 being therefore, as we have elfe where 
 ihown*, incapable of yielding purulent 
 matter, a continued courfe of warm ap- 
 plications, inflead of producing the wifhed 
 far effedl, muft in all probability rather 
 tend CO aggravate all t)ie fymptoms ; for 
 when i'uch remedies do not induce a free 
 fuppuration, the heat they convey to the 
 parts, by adding as a perpetual ftimulus, 
 muft rather tend to increafe the inflamma- 
 tion : And in fadl we find, in the com- 
 plamt now under confideration, that all 
 fuch applications, inftead of being produc- 
 tive of any advantage, rather do harm. 
 The heat of the part is here one of the mofl: 
 diflrefling fymptoms ; fo that, inftead of 
 affording relief, warm emollient applicar 
 tions rather tend to augment this very tor- 
 menting fource of uneafinefs. The lips of 
 
 the 
 
 * Vide Treatlfe on Inflammation and its confe- 
 
 quences. 
 
Sea. IV. Of Blood4etting. 135 
 
 the wound, from not being capable of pro- 
 ducing a good fuppuration, are, by the ad- 
 ditional heat applied to them through the 
 medium of fuch applications, rendered fliJl 
 more hard, fwelled, and of courfe more 
 painful, and the fwelling of the contiguous 
 parts alfo becomes more difFufed over the 
 reft of the member. 
 
 ByAmbrofe Pare, Dionis, Heifter, and 
 others, inftead of emollient remedies, oil 
 of turpentine, tindure of myrrh, and other 
 heating applications, are recommended. 
 That thefe would not prove efFe(5lual, I 
 <:annot from experience pretend to fay . 
 for, fufpedling their powerful ftimulatmg 
 €flfe(5ls might in cafes of this nature prove 
 too irritating, for parts already by difeafe 
 rendered exquifitely fenlible, I have never 
 ventured to ufe them : But I can from 
 repeated experience aiTert, that cooling 
 aftringent applications aiford much more 
 €afe, and, upon the whole, in all fuch ail- 
 ments, prove much more efFedlual, thaa 
 warm emollients ; and of this clafs, the 
 inoft efFedual I have ever ufed are the fa- 
 I ^ turning 
 
1 ;^6 Of Bloodletting, Chap. III. 
 
 turnine applications. The parts chiefly 
 afFecled being alternately covered witl^ 
 cloths wet with a folution of faccharum 
 faturni, and pledgits fpread with Gou- 
 lard's cerate, are kept more cool and eafy 
 than by any other remedy I have ever hap- 
 pened to ufe. 
 
 In all fiich cafes^ therefore, as foon as 
 a number of leeches proportioned to the 
 violence of the fymptoms have been ap- 
 plied to the parts chiefly afFecled, and have 
 difcharged a fufEcient quantity of blood, 
 the fwelling ought to be covered with 
 pieces of foft linen wet in the faturnine 
 folution ; and thefe being kept conflantly 
 . moift for the fpace of a few hours, iliould 
 be fucceeded by Goulard's cerate ; and 
 thus every part in any degree afleded, 
 ought to be alternately covered with one 
 or other of thefe applications, as long as 
 any degree of fwelling remains. 
 
 The febrile fymptoms which occur, muft 
 at the fame time be attended to, by keep-, 
 ing the patient cool; on a low diet; prefer- 
 ving a lax Rate of the bowels; and, if ne~ 
 
 cefTary^ 
 
Bea.IV. Of Blood-letting. 137 
 
 ceflary, farther quantities of blood ought 
 to be evacuated. 
 
 For the violence of the pain, which is 
 fometimes fo exceflive as to deftroy the 
 patient's reft entirely, opiates ought to be 
 freely exhibited ; and when twitchings of 
 the tendons and other convulfive fymptoms 
 fupervene, medicines of this kind become 
 flill more particularly neceflary. In order, 
 however, to have a proper influence in this 
 flate of the complaint, opiates ought to be 
 given in very fulldofes; otherwife, inflead 
 of anfwering any good purpofe, they con- 
 ftantly tend to aggravate the different fymp- 
 toms, not only by increafing the heat and 
 reftleffnefs, but by having an evident in- 
 fluence in rendering the fyflem more fuf- 
 ceptible than it was before of the pain and 
 other diftrefliiig effeds prodaced upon it 
 by the wound : Whenever opiates there- 
 fore are in fuch circumfl:ances employed^ 
 the dofes ought always to be confiderable. 
 
 It often happens, however, in this very 
 alarming diforder, either from neglecting 
 the matter altogether on the accident firft 
 
 happening, 
 
138 Of Blood-letting, Chap. III. 
 
 happening, as is too frequently the cafe, 
 or from an improper fubfequenc treatment 
 by warm emollient applications, that opi- 
 ates and all the other remedies enumera- 
 ted are afterwards ufed without any ad- 
 vantage whatever : The fever, pain, and 
 fwelling of the parts continuing, convul- 
 five alFedions of the mufclcs at laft oc- 
 cur ; all tending to indicate the moft im- 
 minent danger. In this fituation, if we 
 have not immediate recourfe to fome ef- 
 fecflual means, the patient will foon fall a 
 viclim to the diforder ; and the only re- 
 medy from which much real advantage 
 is to be expelled, is ^free and extenfive di- 
 nAfion of the parts in which the orifice 
 producing all the mifchief was at firft 
 made. We know well from the repeated 
 experience of ages, that much more pain 
 and diftrefs of every kind is commonly 
 produced by the partial divifion either of 
 a nerve or of a tendon, than from any of 
 thefe parts being at once cut entirely 
 acrofs. Now the intention of the opera- 
 tion here recommended, is, to produce a 
 
 complete 
 
Sea. IV. Of Blood-letting. E39 
 
 complete divifion of the nerve or tendon 
 we fuppofe to have been wounded by the 
 point of the lancet, and which we confi- 
 der as the fole eaufe of all the fiibfequent 
 diftrefs. 
 
 The operation now recommended being 
 attended with a good deal of pain, and be- 
 ing put in pradlice for the removal of fymp-- 
 toms from which it is perhaps difficult to 
 perfuade the patient that much danger is 
 to be apprehended, all the remedies we have 
 mentioned fhould be firft made trial of be- 
 fore it is propofed: But at the fame time, 
 care ought to be taken, that the diforder 
 be not allowed to proceed too far before we 
 have recourfe to it; for if the patient fhould 
 be previoufly much weakened by the feve- 
 rifh fymptoms having continued violent for 
 any length of time, neither the remedy now 
 propofed, nor any other with which we are 
 acquainted, would probably have much 
 influence. As foon therefore as the courfc 
 already prefcribed has been fairly tried, 
 and is found to be inadequate to the ef- 
 feds expeded from it, we ought imme- 
 diately 
 
140 Of Blood-lettings Chap. Ill, 
 
 diately to have recourfe to a free divifion 
 of the parts chiefly afFedled; and the man- 
 ner of doing it is this. 
 
 As all the contiguous parts are now fup- 
 pofed to be much fwelled and in a ftate of 
 high inflammation, it is impoflible to get 
 proper accefs either to the nerve or tendon, 
 cut by means of a large and extenfive in- 
 cifion; and as this cannot be afFeded v^ith- 
 out fome rifli, of opening at leafl: fome large 
 branches of arteries, the firfl; flep to be 
 taken in this operation is, to fecure the 
 parts, againft the efFecfls of fuch an occur- 
 rence, by the application of the tourniquet 
 on the fuperior Tpart of the member. This 
 precaution is neceflary, not only for guard- 
 ing againfl; the lofs of blood which would 
 enfue from a divifion of any of the large 
 arteries, but for preventing that interrup- 
 tion which would otherwife be occafioned 
 by a conftant difcharge of blood from the 
 fmaller veflels during the operation. The 
 tourniquet indeed is more particularly re- 
 quiflte with a view to the prevention of 
 this lad inconvenience, than for any other 
 3 reafon; 
 
Sea. IV. Of JBIood'Iettlng, 141 
 
 reafon; for although it is proper by means 
 of it to guard againft the efFecls to be ex- 
 pecled from a divifion of any of the large 
 arteries, yet with proper caution fuch an 
 occurrence may in mod cafes be very eafily 
 avoided. 
 
 The tourniquet then, being properly ap- 
 plied, a tranfverfe incifion fhould be made 
 with a common fcalpel*, upon the parts 
 chieily affeded, and it ought to run in a 
 direction exadlly acrofs the original orifice 
 in the vein. 
 
 In every furgical operation, raihnefs is 
 undoubtedly improper, and is often pro- 
 dudlive of difagreeable confequences ; but 
 unneceffary caution, which almofl con- 
 flantly proceeds from the operator being 
 inaccurate and confufed in his ideas of the 
 anatomy of the parts, generally produces 
 fuch a degree of timidity, as ultimately 
 proves more hurtful to the patient, than 
 even an unufual degree of boldnefs ; for 
 in every operation where an incifion is 
 neceffary, if the firft cut is not made fully 
 
 fufficienc 
 *■ For the moft proper form of a fcalpel, fee Plate IV.. 
 
142 OfBlood'Wwg, Cliap. IIIa 
 
 fuSicient for the intended purpofe, all the 
 lubfequent fteps of it are commonly either 
 much retarded, or perhaps rendered en- 
 tirely ineflPe(5liial. 
 
 In no oneration whatever, is it more ne- 
 ceflary than in this, to adl with proper 
 fredom in laying the parts fufficiently 
 open by the external incifion. A fmall in* 
 ciiion puts the patient to nearly the fame 
 degree of pain as a larger cut; and it has 
 this material inconvenience, that the fur- 
 geon cannot go on with the future fteps of 
 the operation with fo much eafe and ex- 
 pedition as when an exteniive opening is 
 made at firft. 
 
 The external teguments being thus freely 
 divided, the operator is now to proceed in 
 a gradual manner, making one flight in-^ 
 cifion after another, taking care, if pof- 
 fible, to avoid wounding either the larger 
 arteries or veins ; and he is to go on in this 
 way, to endeavour to dete^fl the wounded 
 nerve; or if there is no poflibility of doing 
 fo, even by great caution and nicety in 
 wiping av»ray with a fponge every particle 
 
 i2 of 
 
Sea. IV. Of Blood-letting. 143 
 
 of blood as he goes along, he muft ftill 
 continue to proceed in this flow gradual 
 manner, till he has divided every part be- 
 tween the flcin and periofteum; the ten- 
 dons, larger arteries, and veins excepted. 
 
 At this time the tourniquet ihould be 
 loofened; and in all probability the pa- 
 tient will be found to exprefs much fatis- 
 fadion at what has been done : For, if the 
 part is thus divided which originally had 
 been pricked by the lancet, and from 
 whence all the fubfequent diftrefs pro- 
 ceeded, an immediate relief will now be 
 obtained ; but, on the contrary, if the pain 
 flill continues violent, we are thereby ren- 
 dered almoft certain that the mifchief lies 
 altogether in one or other of the tendons. 
 An accurate examination, therefore, muft 
 now be made, by clearing the parts eiFec- 
 tually with a fponge ; and that tendon ly- 
 ing moft contiguous to the vein in which 
 the orifice was made, will in all proba- 
 bility be found either wounded, or in an 
 evident ftate of inflammation ; but at all 
 events, whether any fuch appearances are 
 
$44 Of Blood-letting. Chap, lit 
 
 detecfled or not, no heficatoin whatever 
 fhould occur as to the propriety of divi- 
 ding that tendon which lies mod contigu- 
 ous to the vein ; or if two or even three ten- 
 dinous extremities fhould happen to liein 
 the way, and to be all therefore equally 
 liable to fufpicion, they ought all un- 
 doubtedly to be cut entirely acrofs; and 
 this being properly effedled, it will feldom 
 happen that relief is not immediately de- 
 rived from it : And at any rate, this be- 
 ing done, every attempt will have been 
 made from which we could expedl any 
 benefit. 
 
 The parts having been thus freely divi- 
 ded, the tourniquet muft now be made as 
 flack as pofhble; and fuch arteries as have 
 been wounded muft be properly fecured. 
 The parts are then to be covered with foft 
 eafy drefhngs, and to be afterwards treated 
 in the fame manner as a wound from any 
 other caufe. 
 
 The remedy here recommended, if every 
 clrcumftance is not duly attended to, may 
 probably be confidered as fevere; for fuch 
 
 an 
 
Sea. IV. Of Blood4.dting, 1 45 
 
 an inciiion carried to fuch a depth, muft 
 no doubt be attended with much pain 5 
 and the diviiidn of one or more tendons 
 runs a confiderable riili of producing ac 
 lead a partial lamenefs, and that too proba- 
 bly for life, of the whole member : But if we 
 confider for a moment the importance of 
 the objecl in view, every confideration of 
 this kind muft immediately Icfe all weight. 
 It is not a trifling advantage we are in pur- 
 fuit of, nor can fuch a painful operation be 
 ever with propriety recommend-ed except in 
 very urgent circumftances. In the prefenc 
 inftance, however, it is clear that the pa- 
 tient's life is in all probability to depend o\\ 
 the event of this operation ; fo that the 
 moft timid operator, if he is at all capable 
 of refleclion, muft admit the propriety of 
 putting it in practice ; and from the event of 
 almoft every cafe of this nature, that has once 
 advanced to the length for which v/e have 
 recommended the operation in queftion, id 
 may wnth great certainty be pronouncedj 
 that every patient in fuch circumftances ia 
 in the utmofl hazard of his life ^ fo that in 
 Vol, I. K f«ck 
 
l/\.6 Of Blood-letting, Chap.Ill^ 
 
 flich a defperate fituation, no remedy that 
 affords any tolerable chance of a recovery, 
 however painful it may be, can with pro- 
 priety be condemned. 
 
 From reafoning alone, we would readily 
 conclude, that in all fuch circumfta-nces no- 
 remedy whatever would more probably 
 prove fuccefsful than the operation w^ 
 have now advifed ; but when the pro- 
 priety of the meafure is enforced by the 
 fuccefsful iffue of repeated trials, no argu- 
 Hient adduced againft it ought to meet with 
 much atuencion. In different occurrences 
 of this kind, of lefs importance, I have feen 
 much advantage enfue from the pracflicc 
 here recommended ; but in one inftance, 
 where the patient had been blooded in the 
 median cephalic vein of the arm, the dil- 
 order had got to fuch a height, and had fo 
 obftinately reiirted every other remedy^ 
 that there was every reafon to fuppofe 
 death mull have enfued, had it not been 
 for the effedls of a free and very deep in*- 
 cifion made into the parts affecled. The 
 patient, from being evidently in very great 
 
 ha^zardv 
 
Sea. IV. Of Miood-kttmg. i^f, 
 
 liazard, and'in exquifite pain, experienced 
 dlmoft inftantaneous relief; and the {well- 
 ing, which had previoudy relifted the ef- 
 fecfls of every other remedy, and had even 
 continued to fpread, began foon to abate, 
 and a perfect recovery was obtained in a 
 much ihorter fpace of time than could 
 have been expe^ed. 
 
 There is not therefore a point in far- 
 gery that I am more fatisfied ofj thari 
 the propriety of fuch an operation in all 
 fuch defperate cafes as the one we have 
 been treating of ; but to fuch as have not 
 happened to meet v^ith occurrences of this 
 nature, the remedy propofed will not only 
 appear to be too violent for the difeafe, but 
 they will alfo be induced to confider the 
 length of difcuflion here gone into to be 
 touch more prolix than is neceifary : A fin- 
 gle inftance, however, of the dreadful fymp- 
 toms now and then induced by accidents 
 of this kind, will be fully fufRcient to con- 
 vince any man, that the fubjefl now un- 
 der coniideration is perhaps one of the mod 
 important in the department of furgery. 
 
 K 2 All 
 
F-4S Of Blood-letting Chap. IIL 
 
 All thai has hitherto been faid on blood-* 
 letting relates to the operation in general : 
 We {hall now proceed to confider the ope- 
 ration as it is put in pradice in particular 
 parts ; and firft of blood-letting in the arm. 
 
 SECTION V. 
 
 Of Blood-letting in the Arm. 
 
 LOOD-LETTiNG is more frequently 
 praclifed on the fore- part of the arm 
 at the joint of the elbow, than in any other 
 part of the body. The v-eins are in general 
 more confpicuous in this place; but no 
 other reafon can be affigned for this prefe- 
 rence; On the contrary, the near contiguity 
 of nerves, tendons, and of large arteries, to 
 thefe veins, makes the -operation more ha- 
 zardous- here than in any other part. From 
 this circumftance, therefore, I have often 
 been induced to confider the fixing on this 
 part for the ordinary operation of blood- 
 letting, as a very capital error ; and the 
 more efpecially as blood may be drawn 
 from veins in other parts with the fame 
 
 eafe 
 
Sed. V. Of Blood' letting, 149 
 
 eafe as from thofe of the arm, and with 
 much lefs danger; particularly from the 
 veins of the neck, from thofe of the under 
 part of the legs, ankles, and feet. 
 
 Blood-letting in the lower extremities 
 has indeed in generai been confined to a 
 particular fet of diforders ; chiedy to thofe 
 of females: But no good reafon, I imagine, 
 can be affigned for this ; for it is now well 
 known, that, in general blood-letting, the 
 place from whence the blood is drawn, is 
 of little importance, and that the effedls of 
 the operation depend almoft folely upon the 
 quantity of blood that is difcharged in a 
 longer or fhorter fpace of time. 
 
 Blood-letting at the arm may be fafely 
 performed by a furgeon of fteadinefs and 
 attention, as in the hands of fuch a man 
 there can be little or no rifli of the lancet 
 going deeper than the vein, and in this 
 cafe nothing bad can enfue : But, in or- 
 dinary pradice, 1 fhould at all times rather 
 incline to have the operation done in fome 
 other part. It may almoft always be done 
 with eafe in the feet and ankles j and if the 
 K 3 - operation 
 
ISO - Of Blood-letting, Chap.lII. 
 
 operation is properly performed, the fame 
 quantity of blood may be drawn from the 
 veins of thefe parts, as from veins of an 
 equal fize in any other part of the body. 
 
 But whether the idea now fuggefted 
 llionld ever be generally adopted or not, 
 this is fo far evident, that if the cautions 
 we have pointed out are proper on every 
 occafionwhen venaefe(5lion is prafftifed, they 
 are necelTarily macli more fo when the ope- 
 ration is done in the arm, where the veins 
 lie fo very contiguous to parts which can- 
 not be wounded without producing very 
 alarming fymptoms. 
 
 Having already confidered with minute- 
 nefs the various fteps of the operation of 
 blood-letting, ih far as they relate to it in 
 Ji general v/ay ; in order to avoid repeti- 
 tions, nothing vnW now be pointed out but 
 what is particularly required in perform- 
 ing this operation in the arm. 
 
 In applying the ligature for the ftoppage 
 of the cii'culalion, it ought to be placed 
 about an inch or an inch and half above 
 the joint of the elbow ; and, in order to 
 
 prevent 
 
Sect.V. Gf Blood- kiting, i^-i 
 
 prevent the ends of it from interfering with 
 the lancet, the knot fliould be made on the 
 outfide of the arm. In general, one knot 
 might anfwer ; but a flip- knot being made 
 above the firfl, renders it more fecure, and 
 •it is very eafily done. 
 
 In making choice of a vein from wrhence 
 blood is to be taken, the general rules we 
 have already laid down upon this point 
 mud be here particularly attended to. 
 That vein which appears mofl confpicu- 
 x)us, at the fame time that it rolls lead 
 under the'fkin, fhould in general be fixed 
 upon ; but when an artery is found to lie 
 immediately below, and quite contiguous 
 to fuch a vein, the operator, if he is not 
 perfedlly fatisfied with his own fleadinefs, 
 ought rather to take fome other. In ge- 
 neral, however, the artery lies fo low in 
 this place, that the median balilic vein, 
 under which it commonly runs, may be 
 opened with perfedl fafecy ; and as this vein 
 in general appears more confpicuous than 
 any of the others, probably from the con- 
 tinued pulfaticn of the artery below ob- 
 K 4 ftruding 
 
)^j2 Of Blood-ldting. Chap. III. 
 
 {Iru6i:ing in fome meafure the paflage of 
 its concents, it is for this reafon therefore 
 to be made choice of rather than any of 
 the reft. Other circumflances occur too, 
 ■which render the median bafilic prefer- 
 able to the cephahc or madian cephalic 
 veins for the operation of olood- letting. 
 The former, viz. the median bafilic, is lefs 
 deeply .covered with cellular fubllance, 
 and by lying towards the inner part of 
 the arm it is more thinly covered with 
 the tendinous expanfion of the biceps 
 inufcle, than either of the others. From 
 thefe circumftances the operation is always 
 attended with lets pain when done in this 
 \ein than in any of the others ; and that 
 confideration alone ought to have a good 
 deal of influence in determining the choice 
 of an operator. 
 
 In blood-letting at this part of the arm, 
 although the operation may be done with 
 the right hand either upon the right 
 or left arm of the patient ; yet it is 
 much more neatly done by performing 
 With the ri^ht hand upon the right arm, 
 
 and 
 
Seel. V. Of Blood-letting, '53 
 
 and with the left hand upon the left: 
 arm of the patient ; and whoever attempts 
 the contrary, mud find that it cannot be 
 done but in a very aukward manner, as the 
 operator can never in any other way apply 
 his hand propierly to the patient's veins. 
 
 In very corpulent people, it fometimes 
 happens, that all the larger veins lie fo deep 
 as not to be difcovered by the eye; but 
 when they are fenfibly felt by the fingers, 
 even although they cannot be feen, they 
 may be always opened with freedom. In a 
 few inftances, however, it is the cafe, that 
 they can neither be diftinguifhed by the 
 eye, nor by the finger: In fuch a fituation, 
 as they may in general be met with about 
 the wrift, or on the back part of the hand, 
 the ligature fhould be removed from the 
 upper part of the arm ; and being applied 
 about half-way between the elbow and 
 wrlft, the 'veins below will thereby be 
 brought into view ; and wherever a vein 
 can be evidently obferved, there can be 
 no danger in having recourfe to the ope- 
 ration. 
 
 SEC- 
 
154 Of Blood-letting, Chap.IIL 
 
 SECTION VI. 
 
 Of Blood-letting in the Jugular Vein, 
 
 TpOR inflammation of the throat, difor- 
 ders of the eyes, and other afi'ed:ions 
 of the head, when it is wifhed to evacuate 
 blood from veffels near to the parts afFedt- 
 ed, it is frequently judged proper to open 
 the external jugular veins ; and the man- 
 ner of doing the operation is this : 
 
 There is only one ramification of this 
 vein, viz. its principal pofterior branch, 
 which can eafily be brought fo much into 
 view, as to be with propriety opened ; and 
 even this lies deeply covered with parts, 
 not only with the fkin ai>d cellular fub- 
 Hance, but with the fibres of the platifma 
 myoides mufcle, fo that a confiderable 
 degree of prefTure becomes necefTary in 
 order to raife it to any height. With a 
 view to produce this, the operator's thumb 
 is commonly advifed to be placed upon 
 the vein, fo as to comprefs it efFeclually 
 labout an inch or inch and half below where 
 
Sea. VL of Bhod'IeUing, 155 
 
 the opening is to be made. This, how- 
 ever, ieldom proves fufficient for the pur- 
 pofe, as the blood, orA being flopped in its 
 progrefs through this branch, eafily finds 
 a pafTage to the other veins ; fo that un- 
 lefs the principal vein on the other fide of 
 the neck be alfo comprefTed, the vein to be 
 opened can never be fully diftended. In 
 order to diftend it fufficiently, a firm com- 
 prefs of linen fliould be applied on the lar- 
 geft vein on the oppofite fide of the neck; 
 and. an ordinary garter, or any other pro- 
 per ligature, being laid direcftly over it, 
 fhould be tied with a firm knot below the 
 oppofite arm-pit; taking care to make fuch 
 a degree of prefiTure, as to put an entire 
 flop to the circulation in the vein, which 
 in this way it is eafy to do without pro- 
 ducing any obfliruction to the patient's 
 breathing. 
 
 This being done, and the patient's head 
 being properly fupported, the operator, 
 with the thumb of his left-hand, is now 
 to make a fufficient prefiTure upon the vein 
 tp be opened, and with the lancet in his 
 
 right- 
 
l^G Of Blood-letting. Chap. III. 
 
 right-hand is to penetrate at once into the 
 vein ; and, before withdrawing the inftru- 
 ment, an orifice- fhould be made large 
 enough for the intended evacuation. It 
 may be proper to obferve, that a more ex- 
 tenfive opening ought always to be made 
 here than is neceffary in the arm, other- 
 wife the quantity of blood is generally 
 procured with difficulty : And befides, 
 there is not the fame neceffity for caution 
 on this point here that there is in the arm : 
 for it feldom or never happens, that any 
 difficulty occurs in this fituaticn, in put- 
 ting a (top to the blood after the prefFure 
 is removed from the veins ; all that is com-, 
 moniy neceffary for this purpofe being a 
 fiip of adhelive plafter, without any ban* 
 dage whatever. 
 
 In order to bring the vein more clearly 
 into view, fo as afterwards to be able to 
 open it with more exa(^nefs, it has been 
 diredled, that the fldn, cellular fubilance, 
 and mufcular fibres covering the vein, 
 fliould be previoufly divided with a fcal- 
 pel before attempting to pufh the Ian* 
 
 cet 
 
Sea.VIL Of Blood-letting. n^i 
 
 Get into it. There is not, however, any 
 neceflity for this precaution, as it rarely 
 happens that any difficulty is experienced 
 in procuring a free difcharge of blood by 
 opening the vein and teguments at once in 
 the manner diredled : And it is here, as in 
 every inftance where it is neceiTary to take 
 blood by a lancet, if it be not done at once, 
 the patient is much difappointed, and is 
 fure to attribute the failure entirely to a 
 fault in the operator. 
 
 SECTION VIL 
 
 0/ Blood-letting in the Ankles and Feet, 
 
 'XTTTHAT has already been faid on the 
 operation of blood-letting, renders 
 it quite unnecefTary to be here in any de- 
 gree minute. When blood is to be dif^ 
 charged from the veins of thefe parts, it 
 will be readily underftood, that the firft 
 ftep to be taken is a proper compreffion of 
 the veins, fo as to produce an accumula- 
 tion of their contents. The ligature for 
 this purpofe being applied with a fuffici ens 
 
 degree 
 
358 Of Blood-letting. Cliap. lit 
 
 degree of clghcnefs a Utile above the ankle- 
 joint, all the branches of the vena faphena, 
 both in the infide and outfide of the foot, 
 come at once into view ; and as this vein 
 lies everywhere very fuperficial, being in 
 general covered with ikin only, where- 
 ever a proper vein appears confpicuoufly 
 it may with fafety be opened. 
 
 With a view to encourage the difcharge 
 of blood, it has been a conflant pradlice 
 in blood-letting in thefe veins, to dip the 
 feet into warm water immediately on the 
 orifice being made. But this is a very 
 inaccurate method of proceeding, as the 
 quantity of blood taken in this manner 
 can never be afcertained with precilion ; 
 for the blood being all mixed with the wa- 
 ter, the operator can never be in any de* 
 gree certain as to this point : And befides, 
 there does not appear to be any neceffity 
 for this affiflance; for, when the compref* 
 fion of the fuperior part of the veins is 
 made efFedlual, and the orifice is of a pro- 
 per Gze, I never found more difficulty in 
 obtaining a full difcharge of blood from 
 1 the 
 
Sea. Vll. Of Blood'ktthig. 1 59 
 
 the veins of thefe parts, than from any 
 other veins of the body. 
 
 On removing the Hgature, the difcharge 
 is generally flopped at once ; fo that a 
 piece of adhefive plafler applied over the 
 orifice, anfwers all the purpofes of a ban- 
 dage. 
 
 Thefe are the feverai parts from whence 
 blood is ufually taken by vensefecflion ; bat 
 on fome occafions, where the contiguous 
 parts have been particularly affetfled, it has 
 been thought advifable to open 'the veins 
 of other parts, viz. thofe of the tongue, 
 of the penis, the external hemorrhoidal 
 veins, &c. When it is found neeefTary to 
 difcharge blood in this manner from the 
 penis, the veins can be eafilj brought into 
 view by producing an accumulation of 
 their contents in the fame manner as in 
 other parts of the body, through the inter- 
 vention of a ligature : But, in the tongue, 
 in the hemorrhoidal veins about the anus, 
 and other parts where comprefTion cannot 
 be applied, all that the furgeon can do, is, 
 to make an orifice of a proper iize in that 
 
l6o Of Blood-letting, Cliap. ilL 
 
 part of the vein which fhows itfelf moft 
 evidently ; and if a fufficient difcharge of 
 blood is not thus produced, as there fs no 
 other method of efFedting it, immerling the 
 parts in warm water may in fuch eircum- 
 ftances be a very necefTary meafure. 
 
 Having thus confidered the various modes 
 of difcharging blood by vensefedlion, we 
 now proceed to arteriotomy. 
 
 SECTION VIII. 
 
 Of ArteriDtomy, 
 
 "IXZHatever particular advantages may 
 in theory have been expected from 
 arteriotomy, and however fome of its fup- 
 porters may in their clofets have recom- 
 mended it, not only as being in many in- 
 llances preferable to vensefection, but as 
 an operation perfedlly fafe even in vefTels 
 of confiderable iize; yet the moft ftre- 
 nuous friends to the pradice, have flirunk 
 from attempting it on the larger arteries. 
 Inftances have no doubt occurred of large 
 arteries having been opened without any 
 \ dan-* 
 
Sed. VIIL Gf Bhod^ldfing, i 6i 
 
 danger enfuing ; but thefe are To exceed- 
 ingly rare, that no pracliticner of expe^ 
 rlence will be induced by them, delibe- 
 ratelyj or from choice, to open any con- 
 fiderable artery. The fmaller branches 
 of arteries may indeed be opened with 
 great fafety when they are not deeply co- 
 vered, and efpecially when they lie conti- 
 guous to bones, as in fuch ficuatlons. fo 
 foon as the quantity of blood intended to 
 be takdn is difcharged, ail farther lofs of 
 blood may be very eafily prevented by 
 compreflion; but the opening of any of 
 the larger arteries muil be always attended 
 with fo much hazard, arid the advantages 
 to be ezpecled from it in preference to 
 vensfedlion are apparently fo trifling, as 
 mud in all probability prevent it from ever 
 being carried into execution. 
 
 There are very few arteries, therefore, 
 which with any propriety can be opened; 
 ■ the different branches of the temporal are 
 the only arteries indeed from v/hence blood 
 in ordinary practice is ever taken : but, if 
 a fanciful pradlitioner fhould at any time 
 
 Vol. I. L in* 
 
1 62 of Blood'tettkg, Olap. 117. 
 
 incline to take blood in this manner from 
 a different part, it may be done with great 
 fafety from one of the arteries running ort 
 each fide of the fingers. About the middle 
 of the lafl phalanx, this artery is fufficientl))^ 
 large for difcharging a contiderable quan- 
 tity of blood ; in mod Cafes it lies very 
 fuperficial, and in thi& fitiiation there can 
 feldom much difficulty occur in putting a 
 flop to' the evacuation. in performing 
 this operation on any of the temporal 
 branches, if the artery lies fuperficial, it 
 may be done with one pufh of the lancet, 
 in the fame manner as was direcfted for 
 venaefed^ion ; but, when the artery lies 
 deeply covered with cellular fubflance, it 
 is always neceffary to lay it fairly open to 
 view, before making the orifice with the 
 lancet: For in all the fmaller arteries, 
 when they are cut entirely acrofs, there is 
 little chance of being able to procure any 
 confiderable quantity of blood from them: 
 as, when divided in this manner, they re- 
 tra(5l Gonfiderably within the furrounding 
 
 parts,^ 
 
Sedi. Vlil. Of Blood-letting. i6j 
 
 parts, which commonly puts a flop to all 
 farther evacuation. 
 
 Some degree of nicety is alfo necefTary 
 in making the opening into the artery, of 
 a proper oblique diredlion, neither quite 
 acrofs, nor dire(5lly longitudinal \ for a 
 longitudinal opening never bleeds fo free- 
 ly, either in an artery or in a vein, as when 
 its direction is fomewhat oblique. 
 
 If the opening has been properly madej 
 and if the artery is of any tolerable fize^ 
 it will at once difcharge very freely with- 
 out any comprefBon \ but when the eva- 
 cuation does not go on fo well as could be 
 wifhed, the difcharge may be always af- 
 iifled by comprefTing the artery imme- 
 diately above the orifice, between it and 
 the corfefpondiiig veins. The quantity of 
 blood being thus difcharged, it will com- 
 monly happen, that a very flight compref-^ 
 fion on thefe fmaller arteries will fuffice 
 for putting a flop to the evacuation : Buc 
 any degree of prefTare that is found necef- 
 fary may be applied here as in venasfedlon, 
 by means of a linen comprefs and roller ; 
 L 2 the 
 
164 Of Blood' letting. Chap. IlL 
 
 the orifice being firft eiuirely cleared of 
 blood, and properly covered with a bit of 
 adhelive plafter. If that fhould not be 
 found to anfwer, a comprefs of linen fhonld 
 be applied over it, the whole being then 
 to be fecured with a roller. 
 
 It happens, however, in fome inflances, 
 that this does not fucceed, the orifice con- 
 tinuing to burft out from time to time, fo 
 as to be produclive of much diltrefs and 
 inconvenience. 
 
 In this fituation there are three differeni: 
 methods by which we may with tolerable 
 certainty put a flop to the farther difcharge 
 of blood. I/?, If the artery is fmall, as all 
 the branches of the temporal arteries com- 
 monly are, the cutting it entirely acrofs^ 
 esadly at the orifice made with the lan- 
 cet, by allowing it to retracfl within the 
 farrounding parts, generally puts an im- 
 mediate flop to the difcharge. 2^, When 
 that is not confented to, we have it always 
 in our power to fecure the bleeding veflel 
 with a ligature, as we would do an artery 
 accidentally divided in any part of the 
 
 bodv. 
 
Sea.VIlI. Of Bhod'httkg. i% 
 
 body. And, laftlv, if neither of thefe me* 
 thods is agreed to by the patient, we can, 
 by means of a conllant regular preflure, 
 obliterate the cavity of the artery at the 
 place where the operation has been per- 
 formed, by producing an accretion of its 
 lilies. Different bandages have been con- 
 trived for compreffing the temporal artery; 
 but none of them anfwer the purpofe fo 
 tafily and fo effe<flually as the one repre- 
 sented in Plate VI. fig. 3. 
 
 As feme time, however, is required to 
 obliterate the cavity of the artery, this me- 
 thod is accordingly more tedious : but to 
 timid patients it generally proves more ac- 
 ceptable than either of the other two. 
 
 Having thus finiilied the confideratlon 
 of the various methods employed for eva- 
 cuating blood from the larger arteries and 
 veins, we now proceed to the confidera- 
 it^pn of topical blood-letting. 
 
 I. 3 SEC- 
 
1 66 Of Blood-letting. Chap. Ill, 
 
 SECTION IX. 
 
 Offop'ual Blood-letting, 
 
 II7HEN, either from the feverity of ^ 
 local fixed pain, or from any other 
 caufe, it is wifhed to evacuate blood dir- 
 redly from the fmall veflels of the pare 
 affecfled inftead of opening any of the lar-r 
 ger arteries or veins, the following are the 
 different methods employed for affecting 
 it, viz. By means of leeches ; by flight 
 fcarifications v/ixXi the flioulder or tdgc of 
 a lancet ; and, ladly, by means of an in- 
 itrument termed a Scarificator, contain- 
 ing from one to twenty lancets or more, 
 fixed in fuch a manner, that when the 
 inftrument is applied to the part affeded, 
 the whole number is by means of a 
 fpring driven fuddenly into it, and to a 
 greater or leffer depth at pleafure. This 
 being done, as it is the fmaller blood- 
 ^eifels pnly th^t by this operation are ever 
 
 intended 
 
!Sedl. IX. Of Blood^iettrng, 167 
 
 intended to be cut, and as thefe do not 
 commonly difcharge freely, fome means 
 cr other become necefTary for promoting 
 the evacuation. 
 
 . Various methods have been propofed 
 for^ this purpofc. GlafTes fitted to the 
 form of the afFedled parts, with a fmall 
 Jiole in the bottom of each, were long ago 
 .contrived ; and thefe being placed upon 
 the fcarified parts, a degree of fudion was 
 produced by a perfon's mouth fufficienc 
 for nearly exhauftin^ the air contained in 
 the glafs : And this accordingly was a 
 fure enough method of increafing the 
 .evacuation of blood to a certain extent *. 
 But, as this was attended with a good deal 
 of trouble, and befides did not on every 
 occafion prove altogether efFeclual, an es- 
 haufling fyringe was at lafl adapted to 
 the glafs, which did indeed anfwer as a 
 very certain method of extracting the aijr 
 contained in it ; But the application of 
 ^Jiis inflruraent for any length of time is 
 L 4 very 
 
 =* f elfus, lib. 2. cap. n. 
 
|68 Of Bkod- letting. Chap. III. 
 
 very troublefonne ; and it is difficult to 
 preferve the fyringe always air-tight. 
 
 The application of heat to the Cupping 
 GlafTes, as they are termed, lias been found 
 to rarify the air contained in them to a 
 degree fufficient for producing a very con- 
 iiderable fuclion. And as the inftrument 
 in this fimple form anfwers the purpofe in 
 view, with very little trouble to the ope- 
 rator, and as it is at all times eafily ob- 
 tained, the ufe of the fyringe has there- 
 fore been laid afide. .The glafTes for this 
 purpofe, it is evident, muft be entire; for if 
 there is the leaft communication allowed 
 between their cavities and the furrounding 
 atmofphere, no efFecl whatever will be pro- 
 duced by them. 
 
 There are different methods en'iployed 
 for thus applying heat to the cavity of the 
 glafs. By fupporting the mouth of it for 
 a few feconds above the flame of a taper, 
 the air may be fafficiently rarified; but if 
 the flame is not kept exacflly in the middle, 
 but is allowed to touch either the fides or 
 bottom of the g^lafs^ it is very apt to make 
 
 it 
 
Bea.IX. Of Blood-ldtlng \^ 
 
 it crack and fly in pieces. A more certain, 
 as well as an eafier method of applying the 
 heat, is to dip a piece of foft bibulous pa- 
 per in fpirit of wine, and having fet it on 
 fire, to put it into the bottom of the glafs, 
 and, on its being nearly eitinguifhed, to 
 apply the mouth of the inflrument diredlly 
 tipon the fcarified part. This degree of 
 ' hear, which may be always regulated by 
 the flze of the piece of paper, and which 
 it is evident ought to be always in propor- 
 tion to the lize of the glafs, if long enough 
 applied proves always fufEcient for rarify- 
 ing the air very efFedlually, and at the fame 
 time, if done with any manner of caution, 
 never injures the glafs in the leaft. 
 
 The glafs having been thus applied, 
 if the fcarifications have been properly 
 made, they inftantly begin to difcharge 
 freely ; and as foon as the inflrument is 
 nearly full of blood, it fhould be taken 
 ^way, which may jbe always eafily done 
 by raifing one fide of it, fo as to give ac- 
 cefs to the external air. When more blood 
 i§ wifiied to be taken, the parts fhould be 
 
 bathed 
 
1^0 Of Blood- letting. Chap. Ill, 
 
 bathed with warm water ; and, being made 
 perfectly dry, another glafs exadly of the 
 fize of the former fliould be inftantly ap- 
 pUed in the very fame manner ; and thus, 
 if the fcarificator has been made to pene- 
 trate to a fiiiEcient depth, fo as to have cut 
 all the cutaneous velTels of the part, almoft 
 any necclTary quantity of blood may be 
 obtained. It fometimes happens, how- 
 ever, that the full quantity intended to be 
 difcharged cannot be got at one place : In 
 fuch a cafe, the fcarificator muft be again 
 applied on a part as contiguous to the other 
 as polTible ; and this being done, the ap- 
 plication of the glalTes muft alfo be renewed 
 as before. 
 
 When it is wifhed to difcharge the 
 quantity of blood as quickly as pofTible, 
 two or more glafTes may be applied at 
 once on contiguous parts previoufly fcari- 
 fted; and on fome occaiions, the quantity 
 of blood is more quickly obtained when 
 the cupping- glafles are applied for a few 
 feconds upon the parts to be afterwards 
 Scarified. The fudion produced by the 
 
 glafTes 
 
Sea. IX. 0/ Blood-letting, 1 7 j 
 
 glafTes may poffibly have fome influence 
 in bringing the more deep-feated veiTels 
 into nearer contacl with the £kin, fo that 
 more of them will be cut by the fcarificator. 
 
 A fufficient quantity of blood being pro- 
 cured, the wounds made by the different 
 Jancets fiaould be all perfecflly cleared of 
 blood ; and a bit of foft linen or charpie, 
 dipped in a little milk or cream, applied 
 over the whole, is the only drefling that is 
 iiecefTary : When dry linen is applied, it 
 not only creates more uneafinefs to the pa- 
 tient, but renders the wounds more apt to 
 fefter than when it is has been previoufly 
 wetted in the manner directed. 
 
 Although this operation is by no means 
 difficult in the execution, yet a good deal 
 of pracflice is necefTary to perform it in a 
 neat and fuccefsful manner ; but with a 
 little attention, any operator may foon be- 
 come fo expert, as to be able to take any 
 quantity of biood by it that can ever be 
 neceffary. 
 
 In fome cafes of local pains, and in others 
 where fuppuration of the part has been 
 
 wiihed 
 
1 72 Of Blood-letting, Chap. III. 
 
 wifhed for, an operation termed dry-^eup' 
 ping has been propofed, and in fome in- 
 ftances its advantages are faid to have pro- 
 ved confiderable. This confifts in the ap- 
 plication of the cupping-glafles diredlly to 
 the parts affecfled, "without the ufe of the 
 fcarificator. By this means a tumor is 
 produced upon the part ; and where any 
 advantage is to be expecled from a de- 
 termination of blood to a particular fpor, 
 it may probably be more eafily accom- 
 pli fhed by this means than by any other. 
 
 In Plate VI. are reprefented a fcarifi- 
 cator, and different fizes and figures of 
 cupping-glafles, with which every opera- 
 tor ought to be amply fupplied, fo as to be 
 able to adapt a glafs to every part from 
 whence it may be proper to dlfcharge blood 
 in this manner. When the part from 
 which it is intended to produce a local eva- 
 cuation of this kind is fo fituated that a 
 fcarificator and cupping- glaffes can be ap- 
 plied, this method is greatly preferable to 
 every other; but it now and then happens, 
 that parts are fo fituated as not to admit 
 
 of 
 
Tlafe V. 
 
 ' ^r ^■ 
 
 ■ ^z- 
 
 -t( 
 
 
 ^ ^r-^ 
 
 c/,/s^yic/^^/^i : 
 
 r- 
 
Se(ft. IX. Of Blood-letting. 1 7^ 
 
 of their application : Thus, in inflamma- 
 tory affedlions of the eye, of the nofe, and 
 of other parts of the face, the fcarificator 
 cannot be properly applied diredtly to the 
 parts affedled. In fuch inftances, leeches 
 are commonly ha^ recourfe to, as they can 
 be placed upon almoft any fpot from 
 whence we would wifh to difcharge blood. 
 ^ In the application of thefe animals, the 
 mod efFed-ual method of making them fix 
 upon a particular fpot, is to confine them 
 to the part by means of a fmall wine-glafs. 
 Allowing them to creep upon a dry cloth, 
 or upon a dry board, for a few minutes 
 before application, makes them fix more 
 readily ; and moiftening the parts on which 
 they are intended to fix, either with milk, 
 cream, or blood, tends alfo to caufe them 
 adhere much more fpeedily than they other- 
 wife would do. So foon as the leeches 
 have feparated, the ordinary method of 
 promoting the difcharge of blood, is to 
 cover the parts with linen cloths wet in 
 warm water : In fome fituations, this may 
 probably be as effe{n;ual a method as any 
 
 other ; 
 
i 74 Of Biood-Utfm^, Chap. \\h 
 
 other J but wherever the cnpping-glalTes 
 cin be applied over the wounds, they an- 
 fvver the purpofe much more efFedually : 
 Wherever the figure of the part, therefore, 
 will admit of their application, they ought 
 Aiiidoubtedly to be employed. 
 
 Among other methods of e£Fe6ling what 
 we term Local Blood-letting, fcarifications 
 with the edge or fhoulders of a lancet was 
 mentioned as one : There are not many in-^ 
 Ilances in which this proves very necefTary; 
 but now and then cafes do occur in which 
 blood may be taken in this manner, whea 
 it cannot w^ith propriety be difcharged by 
 any other means. This is particularly the 
 cafe in fome inflammatory afFedions of 
 the eye, where the ball of the eye is chiefly 
 afFeded, and where general blood-letting 
 and evacuations from the neighbouring 
 parts do not prove efFe61:ual. In fuch af- 
 fedions it frequently happens, that fcari^ 
 fying the veiTels of the tunica conjundlva 
 of the eye, fo as to evacuate perhaps only 
 a very few drops of blood, is produdlive 
 of much advantage. The mere divifion of 
 ?. tiiiPi 
 
Sea. 1^. Of Blood-letting. 1 7^ 
 
 the veflels in fuch cafes, has indeed beent 
 fuppofed to be of ufe; buc I have conftantly 
 obferved, that the advantage produced by 
 this operation, has been in general nearly 
 in proportion to the qxianttty of blood dif- 
 charged by it. 
 
 Different methods have been propofed 
 for performing it, but the eafieft and 
 mod effedlual, is by means of the edge or 
 fhoulder of a lancet. For this piirpofe, 
 the upper eye-lid being fupported by the 
 hand of an affiftant, and the under pal- 
 pebra being fecured by the fingers of the 
 operator's left-hand, with the lancet in 
 his right-hand, a number of flight fcarifi- 
 cations fhould be made through the diffe- 
 rent veffels that feem to be mofl turgid. 
 In order to fecure the eye properly, it has 
 been advifed to have it previoufly fixed 
 by a fpeculum before attempting to fcarify 
 the veffels. There is not, however, any 
 occafion for this precaution, as the eye may 
 be always made fufficiently fleady for this 
 operation, by gentle prefTure with the 
 fingers in the manner diredled ; and be- 
 
 fides. 
 
tyS of Bluod'ldt'ing, Chap. Iii„ 
 
 fides, in this inflamed (late of the eye, the 
 prelTure produced by a fpeculum is very 
 apt to do mifchief. 
 
 To fuch as have not fecn this operation 
 put in pradice, it may perhaps appear to 
 be too hazardous to be attempted by thofe! 
 who arc not much accuftomed to it ; • buC 
 a very moderate degree of fleadinefs ren- 
 ders it very calily and fafely prac5licable. 
 All the veffels intended to be cut, being 
 freely divided, bathing the eye in warm 
 water is the mod elfediual method of en- 
 couraging the difcharge. 
 
 In the fame manner, fcarilicatlons of 
 this kind may at times be ufefully em- 
 ployed in removing inflammatory affec- 
 tions of the eye-lids j and the fame re- 
 medy may now and then, perhaps, be nfed 
 with advantage in iimilar affecflions of 
 other parts. 
 
 Among other methods that have been 
 propofed for fcarifying the blood-vefre|& 
 of the eye, the beards of roiigh barley 
 were at one period much extolled, and 
 are ftill employed by fome individuals. 
 
 2 
 
Sea. IX. Of Blood-ktting, 17^ 
 
 By drawing them over the furface of the 
 eye, in a dire(5lion contrary to the fharp 
 fpicalx with which they are furnilhed, a 
 coniiderable difcharge of blood is thereby 
 produced. But the pain attending this 
 operation is exquilite; and as it does not 
 pofTefs any fuperior advantage to the me- 
 thod with the lancet, it is now falling into* 
 general difufe. 
 
 We have thus finifhed the confideratiori 
 of the various means employed in furgery 
 for evacuating blood from the fyilem ; and 
 as the diforder termed Aneurifm is fre- 
 quently produced by an unguarded manner 
 of performing one of the operations we 
 have jufl: been defcribing, the farther con- 
 fideration of this fubjedl: cannot, we think, 
 be any where more properly introduced 
 than in this place, where one of the prin- 
 cipal caufes tending to produce it has beeri 
 fo lately treated of> 
 
 Vol, L M G H A P. 
 
178 Of Aneurifins. Chap. IV, 
 
 \ 
 
 CHAI^. IV. 
 
 (y Aneurisms. 
 
 SECTION I. 
 
 General Remarks on Aneurifms^ 
 
 ^T^HE term Aneurifm, was originally 
 meant to fignify a tumor iformed by 
 the dilatation of the coats of an artery; but 
 by modern practitioners, it is made to ap- 
 ply not only to tumors of this kind, but 
 to fuch as are formed by blood efFafed from 
 arteries into the contiguous parts; a cir- 
 
 cumftance 
 
Seifl. L Of Aneurlfms, • 11^9 
 
 cumflance which may happen either from 
 an artery being punctured with a fharp in- 
 ftrumentj or from a rupture of its coats 
 produced by any other caufe. 
 
 The firft fpecies of the diforder, viz. that 
 which depends on an extenllon or dilata- 
 tion of the coats of an artery, has been 
 denominated the True Aneiirifm; and the 
 latter, or that which proceeds from an eiFu-- 
 fion of arterial blood into the furrounding 
 parts, has been commonly termed the Falfe 
 Aneurifm. 
 
 As the introdudlion of new appellations 
 frequently tends to produce confuiion, ne- 
 ceffity alone can juftify the attempt} and 
 accordingly it will rarely happen, in the 
 courfe of the prefent work, that any inno- 
 vation of this kind is made. In the pre- 
 fent inftance, however, as the nature and 
 treatment of the diforder may be rendered 
 more clear and diftindl by a change of 
 terms applied to the different fpecies of 
 aneurifm^ an attempt of this kind may, 
 for fuch a reafon, it is hoped, be made 
 without any impropriety, 
 
 M 2 la 
 
iSo Of Aneurifms, Chap. iV. 
 
 In that fpecies of the diforder depend- 
 ing upon the dilatation of an artery, as 
 the tumor is always circumfcribed, and 
 contained within coats peculiar to itfelf> it 
 may therefore properly enough be termed 
 the Encyfled Aneurifm ; and the other, 
 from the fwelling fpreading extenfively 
 over the neighbouring parts, may with 
 equal propriety be termed the DiiFufed 
 Aneurifm. 
 
 As thefe two fpecies of the diforder are 
 very different from one another, not only 
 in their caufes, appearance, and effedls, 
 but even in the treatment neceffary for 
 their removal; it will be proper, therefore, 
 to enter into a feparate confideration of 
 each of them. 
 
 In the true or encyfted aneurifm, when 
 externally fituated, the tumor when firfl: 
 obferved is commonly very fmall and cir- 
 cumfcribed; the fkin retains its natural 
 appearance; when preffed by the fingers, 
 a pulfation correfponding with that of the 
 artery below is evidently diftinguifhed; 
 and with very little force the contents of 
 
 the 
 
Sed. I. OfAneimfms, i8i 
 
 the fwelling, while they are yet foft and 
 flucluating, may be eafily made to dlfap- 
 pear entirely. 
 
 If means properly calculated for the re- 
 moval of the difeafe are not now put in 
 pradlice, or if upon trial they fhould be 
 found to fail, the fwelling begins to in- 
 creafe, becomes more proniinent, and con- 
 tinues in a gradual manner to acquire a 
 larger lize. For a confidei^able time the 
 fiiin and teguments retain their natural 
 appearance; the patient does not complain 
 of pain, not even on prefTure; the tumor 
 continues of an equal foftnefs; and its con- 
 tents are ftill compreffible, yielding con- 
 fiderably, and in general difappearing en- 
 tirely on the application of prefTure. At 
 laft, however, when the fwelling becomes 
 very large, the fkin lofes its ordinary co- 
 lour, becomes pale, and, in the more ad- 
 vanced ftages of the difeafe, even cedema- 
 tous : The pulfation fiill continues ; but 
 the tumor although foft in fome parts, yet 
 in others is firm, and cannot now be made 
 to yield much upon prefTure, part of the 
 M 3 conralned 
 
i82 OfAneiirifim. Chap. IV. 
 
 contained blood having in this ftage 
 of the difeafe become hard by coagula- 
 tion. 
 
 The fwelling continuing to increafe, in 
 
 a gradual manner it becomes more pain- 
 ful, and produces much diflrefs ; the fkin 
 turns livid, apparently verging to a gan- 
 grenoTis flate: at laft, an oozing of bloody 
 ferum occurs from the teguments; and if 
 a real mortification does not take place, 
 the fkin cracks in different parts; and now 
 the force of the artery not meeting with 
 fo much reiiftance as before, in a very 
 fhort fpace of time, if the veflel is large, a 
 period is put to the patient's exiftence, by 
 the blood burfling out with fuch violence 
 as to produce almofl inftantaiieous death; 
 at lead in the larger arteries of the trunk 
 of the body, this is the' ordinary event of 
 all fuch affedlions. In the extremities, 
 however, the arteries are not fo large as 
 by their rupture to be capable of produ- 
 cing efFe(fls fo immediately fatal; and be- 
 fides, we can here, in general, by .means 
 of the tourniquet, be always certain of 
 
 preventing 
 
Sedl. I. Of Aneiinfms^ i8j 
 
 preventing this fudden termination of the 
 difeafe. 
 
 In aneurifmal afFedlions of the larger ar- 
 teries, the effects produced upon the neigh- 
 bouring parts, by the eonflant pulfation 
 and gradual augmentation of the tumor, 
 are often furprifing. The fofter parts we 
 might, a priori^ expedl to yield to a very 
 confiderable extent ; but the hardefl parts 
 of the body, probably from the very cir- 
 cumftance of their not being capable of yield' 
 ing^ evidently fuffer more from the effects 
 'of this kind of prefTure, than either mem- 
 branes, mufcles, or ligaments. Even the 
 bones frequently undergo a very great de- 
 gree of derangement, by the pulfation and 
 diftenfion of contiguous aneurifms : Some- 
 times they are feparated entirely from one 
 another at the different joints : On fome 
 occafions they are elevated much out of 
 their natural fituations ; and in many in- 
 flances they have been found entirely dif- 
 folved. 
 
 Occurrences of this kind are not com- 
 mon in any of the extremities, as it is the 
 M 4 flrong 
 
184 Of Aneunfms. Chap. IV. 
 
 ilrong pulfacion of the aorta only, or of 
 fome of the larger arteries at no great di- 
 Aance from the heart, that we can ever 
 fuppofe lliould be followed by fuch con- 
 fequences. Now and then, however, fimi- 
 lar effecls of an aneurifm have been ob- 
 ferved in the thigh, and fuperior parts of 
 the arm ; even the bones of thefc parts 
 having been found much affeded by aneu- 
 rifmal fwellings of the neighbouring ar- 
 teries. 
 
 The appearance and termination of en- 
 cyfted aneurifms, are in general very 
 nearly as is here rcprefenred : One ex- 
 ception, however, occurs in a particular 
 fpecies of the diforder, which will after- 
 wards be more accurately defcribed. 
 
 Various caufes may be fuppofed necef- 
 fary to the production of encyfled aneu- 
 rifms. I. We know from daily expe- 
 rience, that partial debility frequently 
 occurs in different parts of the fyftem : 
 Ihus, there is nothing more common 
 tlian cjedematous fwellings of the extre- 
 mities, even in conflitutions otherwife 
 
 healthy % 
 
gedl.I. Of Aneurifms, 1 85 
 
 healthy ; and fwelllngs of this nature, we 
 juftly fuppofe CO depend moft frequently 
 on a local weaknefs of the parts in which 
 they occur. Now, why may not a debi- 
 lity of a fimilar kind fall upon part of the 
 arterial fyftem ? and, if it fhould ever do 
 fo, we can eafily fee how in almoft every 
 inflance it mud neceflarily terminate in 
 aneurifmal fwellings : For the force of the 
 heart continuing the fame, if any parti- 
 cular part of an artery has lofl its tone, as 
 it is thereby rendered incapable of refift- 
 ing the pulfations of the heart, a yielding, 
 or dilatation of its coats, mull at thefe 
 weakened parts naturally enfue ; and as 
 foon as a morbid enlargement of its ca- 
 vity is thus fairly commenced, as its 
 power of refinance will of courfe propor- 
 tionally diminifh, while at the fame time 
 the 'vis a tergo (lill continues equally pow- 
 erful, the farther increafe of the fwelling 
 is a confequence that muft neceflarily en- 
 fue. 
 
 This caufe of the dlfeafe may be conii- 
 ^ered as the moil frequent origin of aneu- 
 
 rifms, 
 
1 8 5 Of Aneurifms, Chap. IV. 
 
 rifms that do not evidently depend upon 
 external injuries : All fuch fwcllings as oc- 
 cur in the courfe of the aorta, feem clearly 
 to depend on this caufe ; as is in general 
 the cafe, indeed, with all fuch as happen 
 internally, in whatever part of the body 
 they may be fituated. 
 
 2. The external coats of an artery being 
 deftroyed by a wound with any kind of 
 inftrument, a partial wcaknefs of the part 
 will be thus produced ; and this muft ren- 
 der it liable to be adled upon to advantage, 
 by the heart and other parts of the arterial 
 fyftem, in the fame manner as if it had 
 been previoully debilitated by difeafe. 
 
 In dilatations of an artery produced by 
 this caufe, the diforder proceeds in the 
 manner we have already defcribed. The 
 blood, from being ftiU confined within the 
 coats of the artery, continues to form a 
 circumfcribed tumor. In the beginning 
 of the difeafe, the fwelling is eafily made 
 to difappear upon prefTure ; but on ad- 
 vancing farther, part of its contents be- 
 come fo firm by coagulation, as to render 
 
 it 
 
Se<El. I. OfAnenrifms. 187 
 
 it impofTible to difcufs it by any degree of 
 preffiire that can with propriety be applied. 
 This fpecies of the diforder may now and 
 then occur from other caufes, but it is 
 moll frequently produced by blood-letting 
 in the arm ; by the lancet, after having 
 pafTed through the vein, going fo deep as 
 to divide the external coats of the ar- 
 tery. 
 
 3. A fimilar eftecfl has been fometimes 
 produced, by the matter contained in 
 neighbouring fores and abfceifes, proving 
 fo corrofive as to deltroy the external co- 
 verings of the contiguous arteries : When 
 this happens to occur, the fame train of 
 fymptoms, it is evident, mufl: fucceed as if 
 the outer coats cyf the velTel had been de- 
 ftroyed by a lancet or any other Iharp in- 
 flrument. 
 
 4. The bones, mufcles, ligaments, &c. 
 with which arteries are furrounded, all 
 ferve as a fupport to thefe veffels, fo that 
 it is not furprifing, that the deftrudlion of 
 any of thefe parts fhould tend to the pro- 
 dudion of aneurifms ; and accordingly 
 
 in- 
 
1 8 8 Of Aneurifins, Chap. IV. 
 
 inflances have occurred, where affedions 
 of this kind feemed evidently to depend 
 on fuch a caufe : Indeed the firmnefs and 
 {lability of any fet of parts naturally con- 
 nedled together, depends fo much upon a 
 found (late of the whole, that any one of 
 them becoming weak and difeafed, gene- 
 rally terminates in a difeafed ftate of all or 
 part of the remainder. In the thigh of a 
 patient where part of the mufcles and other 
 foft parts had been deflroyed by an ex- 
 tenfive mortification, different aneurifinal 
 fwellings occurred in the courfe of the fe- 
 moral artery which had thus lofl part of 
 its fupport ; and no other caufe appeared 
 to be concerned in their produdion. 
 
 5. In blood-letting at the ufual place in 
 the arm, it was already remarked, that ar- 
 teries are fometimes wounded, by the lan- 
 cet pafTmg quite through the vein into ihe 
 artery below ; and when the artery hap- 
 pens to be diredly in contadl with the vein, 
 the blood difcharged from the orifice n ade 
 in the artery, by pafhng diiediy into the 
 vein, ferves to keep up a communication 
 
 be- 
 
Sed. I. Of Anturifms. 289 
 
 between the trunk of the one, and a prin- 
 cipal branch of the other. 
 
 In this manner, a direcft pailage being 
 produced between the artery and vein, 
 and the coats of the latter not being fufE- 
 ciently firm for refilling the impulie of 
 the former, a preternatural dilatation of 
 the vein is a confequence that mufl neceJP- 
 farily follow: A tumor accordingly is very 
 foon produced, which is at firfl fmall and 
 circumfcribed, but by degrees it extends 
 confiderably both above and below the 
 orifice; not only along the courfe of the 
 vein originally wounded, but, on fome oc- 
 cafions, all the veins lying contiguous come 
 to be equally diftended. 
 
 This fpecies of the difeafe was firfl ac- 
 curately defcribed by that celebrated ana- 
 tomifl Do<5lor William Hunter ; and may 
 vyith great propriety be termed the Vari- 
 cofe Aneurifm. Since that period it has 
 been frequently obferved by different prac- 
 titioners ; fo that its nature is now very 
 generally underllood. 
 
 Although the coats of the artery are 
 
 here 
 
igo Of Aneurifms, Chap. IV, 
 
 here fuppofed to be all cut fairly open, io 
 as to produce an immediate difcharge of 
 blood ; yet by the blood being contained 
 ■within the cavity of the veins, this fpecies 
 of the difeafe may with equal propriety 
 be confidered as encyfted as any of the 
 preceding ; and as the treatment of it co- 
 incides much with that of other encyfted 
 aneurifms, the farther confideration of the 
 fubjedl could not, it was imagined, be 
 any where more properly introduced. 
 
 In this fpecies of aneurifm, the fwelling 
 is confined entirely to the veins. Soon af- 
 ter the injury producing it has been recei- 
 ved, the vein communicating immediate- 
 ly with the artery begins to fwell : In a 
 gradual manrier, this enlargement be- 
 comes more remarkable; and when any 
 confiderable anaftomofis occurs near to 
 the part affected, between it and the con- 
 tiguous veins, thefe alfo become much 
 enlarged. By prefiing upon this fwelling 
 of the veins, it may be made to difappear 
 entirely, the blood contained in them 
 being in part pufhed forward in its courfe 
 \ towards 
 
Ssd. I. Of Aneurifms^ 191 
 
 towards the heart, while part of it may 
 poflibly be forced into the artery itfelf ; 
 and, when the tumor happens to be of a 
 conliderable fize, the blood, when it is thus 
 forced out of it, is heard to make a very 
 fingular hiiUng kind of noife. This, when 
 it occurs, is a very charaderiftic fymptom 
 of the difeafe ; but as it is not met with ia 
 every cafe, it becomes necejDTary to point 
 out particularly, fuch circumftances as 
 more certainly ferve to diftinguifh this 
 fpecies of aneurifm. 
 
 In the varicofe aneurifm there is a very 
 lingular tremulous motion difcovered ia 
 the dilated vein, attended with a perpetual 
 hifTmg noife as if air was pafling into it 
 through a fmall aperture. If a firm liga- 
 ture be applied upon the under part of the 
 limb, immediately below the fwelling, and 
 be tied fo tight, as even to flop the pulfe 
 in the under part of the member, the fwel- 
 ling in the veins, on being removed by. 
 preffure, returns inftantaneoufly on the 
 preffure being taken off, and does not ap- 
 pear to be in any degree afFeded by the li- 
 » gacure 
 
tg2 Of Anetirifms, Chap. IV, 
 
 garure below; which it undoubtedly would 
 be, was it not for the dire<5l communica- 
 tion between the trunk of the artery and 
 correfponding vein. The fwelling being 
 removed by prelTmg the blood forward to 
 the heart, and a flight prefiiire being made 
 with the point of the finger on the orifice 
 in the artery, the veins remain perfedlly 
 flaccid, without any fwelling whatever be- 
 ing produced, till the preiTure is removed 
 from the orifice, when they fill again im- 
 mediately ; and this even happens, altho* 
 the prefTure on the artery is not fo firm as 
 to flop the circulation in the under part of 
 the limb. 
 
 In the fame manner, too, if the trunk of 
 the artery be comprefTed above the orifice, 
 fo as to flop the circulation efFs(5lually, 
 that tremulous motion and hifling noife in 
 the fwelling of the veins ceafes inftantly j 
 and, if the veins are now emptied by pref- 
 fure, they will certainly remain fo till the 
 compreflion upon the artery is removed. 
 On fome occafions, too, it happens, that if 
 two ligatures be applied, one an inch or 
 I two 
 
Sed. I. OfAneurifms^ 193 
 
 two above, and the other as much below 
 the fwelling, and are made fo tight, as to 
 ilqp entirely the circulation of the blood 
 in the tumor lying between them ; if the 
 fwelling is now comprefTed, all the blood 
 contained in it is made to pafs into the 
 opening in the artery, from whence it in- 
 ftantly returns again on the prelTure being 
 removed. This, however, does not al- 
 ways happen ; and its not doing fo, is no 
 proof whatever of that fpecies of aneurifm 
 now under confideration not a6lualiy exift- 
 ing ; for if all or feveral of the leading 
 circumflances of the difeafe which we have 
 jull enumerated ever take place, the nature 
 of the diforder is thereby rendered clear - 
 and evident. 
 
 In addition to the other charaderidic 
 fymptoms of the varicofe aneurifm, it may 
 be remarked, that when it has continued 
 for any length of time, io as to have 
 produced a coniiderable dilatation of the 
 veins, the trunk of the artery above the 
 orifice generally becomes preternaturally 
 large, while the branches below become 
 
 Vol. L N pro- 
 
J 94 Of Aneiirifms, Chap. IV, 
 
 proportionally fmall; and of confequence^ 
 the pulfe in the under part of the member 
 is always more feeble than in the found 
 limb of the oppofite fide. 
 
 The reafon of this laft circumftance id 
 obvioufly this ; that the blood, by finding 
 a dife6l pafTage between the trunk of the 
 artery and the principal branch of the 
 correfponding vein, paffes more readily 
 in that way, than by the common courfe 
 of circulation along the under part of the 
 member ; fo that the quantity of blood fent 
 to the inferior extremities of the artery 
 being thus much diminifhed, the pulfa- 
 tion produced by it mufb of courfe become 
 proportionally feeble : But why the fupe- 
 rior part of the artery fhould be enlarged, 
 by the blood paffing thus fo diredlly and 
 eaiily from it into the vein, is a cir<:um- 
 flance not fo eafilv accounted for. The 
 refiftance to the blood paffing through the 
 artery, is by this direcl communication 
 between it and the vein very much dimi- 
 nifhed ; and this has been fuggefted as the 
 caufe of the phenomenon. But this cir- 
 
 Gumftancep 
 
Bed. i. Of Aneurifms, 195 
 
 cumftance, of the refiftance to the pafTage 
 of the blood being thus diiniriilhed, we 
 might more readily expe<5l to have a very 
 contrary efFedl. In other parts of the circu- 
 lating fyftem, we frequently find, that re- 
 fiftance to the pafTage of the fluids termi- 
 nates in a dilatation of the containing vef- 
 fels ; and that fwellings thus produced, can 
 be removed by no other means than the re- 
 moval of that refiftance which firfl gave rife 
 to them. Nothing that can be faid upon 
 this fubjecl, however, will afford much 
 fatisfacSlioTi, as it is merely a fpeculative 
 point; and as it can have no great influence 
 on the pradlical treatment of the diforder^ 
 we fhall not here attempt a farther inve- 
 {ligation of it. 
 
 Having thus enumerated the ordinary- 
 appearances of the different fpecies of en- 
 eifled aneurifmj together with the various 
 taufes which are found to produce them, 
 we Ihall now proceed to defcribe the fymp- 
 toms and caufes of the diifufed smeurifm, 
 and fhall conclude with the treatment of 
 the various fpecies of the difeafe, 
 
 N 2 the 
 
196 Of Aneur'ifms, Chap. IV, 
 
 The Diffufed, or what is commonly term- 
 ed the Falfe Aneurifm, confifts in a wound 
 or rupture of an artery, producing, by the 
 blood thrown out from it, a fwelling, 
 more or lefs difFufed, in the contiguous 
 parts. 
 
 Great bodily exertion has frequently 
 proved an evident means of inducing a 
 rupture of very confiderable arteries feated 
 internally : This we know to be particu- 
 larly frequent in thofe of the lungs, pro- 
 bably from their being in that organ fur- 
 rounded with fuch foft contiguous parts 
 as do not afford them much fupport ; and 
 probably from the contrary reafon, that 
 here the arteries are more firmly fupport- 
 ed, fuch accidents- feldom or never occur in 
 the external parts, where alone they could 
 everbecomethe objecl of a furgeon's atten- 
 tion. We fhall therefore confine our defcrip- 
 tion of this diforder, entirely to that kind 
 of it which we know to be mod frequently 
 produced by a wound made direcftly into 
 an artery, and which it is commonly in 
 the pow^er of art to relieve. 
 
 When 
 
Seel. I. Of Aneurifins. 197 
 
 When treating of the confequences of 
 ■vensefedion in the arm, wounding the 
 contiguous artery was particularly men- 
 tioned as one : In a few inftances, by the 
 treatment then pointed out, any bad effedls 
 which might otherwife occur from this 
 circumftance, will be entirely prevented 
 by the wound in the artery healing with- 
 out any of the ufual confequences being 
 produced by it. Such happy terminations, 
 however, of this accident, are exceedingly 
 rare, and can never with any degree of 
 certainty be depended on. 
 
 When a pundlured artery refills the 
 means employed for preventing the ordi- 
 nary eiFe(fls known to refult from it, it will 
 then for certain terminate in a fwelling of 
 the aneurifmal kind j andfthe following is 
 the ufual progrefs of the dlfbrder. 
 
 A fmall tumor, of about the fize of a 
 horfe bean, generally rifes juft at the ori- 
 fice in the artery, foon after the difcharge 
 of blood has been ftopt by comprefhon : 
 At firfl the tumor is foft, has a flrong de- 
 gjree of pulfation, and yields a little upon 
 N 3 pref? 
 
198 Of Aneiinjms, Chap. IV. 
 
 prefTure. It is never, however, fo com- 
 prefTible as the fwelling of an encyfted 
 aneurifm : For in the latter, except in tlie 
 more advanced flages of the difeafe, the 
 blood remains perfedly fluid, and there 
 is a regular circulation of it through the 
 whole cyil ; whereas, in the diffufed aneu*- 
 rifm, the blood forming the tumor is at 
 once extravafated ; and as in that ftate 
 it loon begins to coagulate, it is not long 
 in acquiring a very firm degree of con- 
 fidence. 
 
 In this ftate of the diforder, if the fwell- 
 ing be not improperly treated by the ap- 
 plication of much preffure, it generally 
 remains nearly of the fame fize for feve- 
 ral weeks, when it begins gradually to in- 
 creafe ; and if feated in the ufual place of 
 blood-letting in the arm, it proceeds ra- 
 ther farther up than the orifice, and ex- 
 tends rather more inwardly than towards 
 the outer part of the arm, probably from 
 the expanlion of the biceps mufcle not 
 being there fo firm and compadl as in 
 the external and under part of the arm. 
 
 This 
 
Sed.L Of Aneiififms^ 89^ 
 
 This enlargement of the tumor, too, pro^ 
 geeds with much more quicknefs in fome 
 inftances than in others, and on fome ccca- 
 cafions the fwelling is much more diffufed 
 and extended than in others. 
 
 Bqth thefe circumftances, it is probable, 
 depend upon the fame caufe. If the blood 
 poured out by an artery, is thrown into a 
 very la^ cellular fubflance, we can eafily 
 fuppofe, that its increafe will not only be 
 more rapid, but that the diffiilion of the 
 tumor mufl for the fame reafon be much 
 more confiderable, than when the artery 
 is immediately enveloped by firm mem- 
 branous or ligamentous parts, which do 
 not fo readily yield to the impulfe of the 
 blood. There is, from this circumftance 
 alone indeed, fuch a remarkable differ- 
 ence in the progrefs of the diforder, that 
 in fome inftances fwellings of this kind 
 have been many months, nay even years, 
 in arriving at any confiderable fize ; and 
 on the contrary, fome inftances have oc- 
 curred of the blood from the orifice in 
 the artery, being diffufed over the whole 
 N 4 ^rm 
 
200 Of Aneurifms, Chap. IV. 
 
 arm from the elbow up to the Ihoulder 
 in the fpace of a few hours from the ope- 
 ration. 
 
 A particular laxity of cellular fubftance, 
 has undoubtedly, in all fuch inftances, a 
 great influence in promoting this rapid 
 difFafion of the cxtravafated blood; but 
 the ordinary pradice in every cafe of a 
 wounded artery, of applying very tight 
 compreffion, I am convinced, has alfo a 
 very great influence in producing the fame 
 efle(5l. In addition to what was faid upon 
 this point in the chapter on Blood- letting* 
 I fliall here jufl: obferve, that if it was pof- 
 Able to produce a moderate degree of pref- 
 fure upon the orifice in the artery alone, 
 fo me advantage might now and then per- 
 haps be derived from it ; but in order to 
 apply a degree of compreflTion fufficient for 
 producing any influence upon the artery, 
 the principal veins in the limb mufl: by the 
 fame means be all fo much aded upon, as 
 to occaiion much obftru<f\ion to the re- 
 turn of blood from the correfponding ar- 
 tery. And v/hatever tends in any degree 
 
 to 
 
§6(^.1. Of Aneurlfms, 201 
 
 to obftru<5l the refluent blood, muft in 
 an equal proportion diftend the wounded 
 artery, and increafe the quantity of blood 
 which efcapels by the orifice. Many ma- 
 chines have indeed been contrived for pro- 
 ducing a partial compreflion upon the ar- 
 tery without affedling the reft of the limb : 
 But however much thefe may have been 
 extolled by their feveral inventors, yet 
 none hitherto difcovered anfwers the pur- 
 pofe of comprefling the artery, without at 
 the fame time tending greatly to ob- 
 Itrudl the circulation in the veins ; info- 
 much that a great deal of mifchief has on 
 different occafions been produced by all of 
 them. 
 
 Whoever inclines to have recourfe to 
 the ufe of thefe inftruments, will find 
 a variety of them delineated in Heifters 
 Syftem^of Surgery, and in Dionis and Plat- 
 ner's works. 
 
 Mr Dionis, an eminent French furgeoHj 
 although in cafes of wounded arteries he 
 recommends the ufual pra<5lice of compref- 
 lion, yet relates a cafe which happened to a 
 
 furgeon 
 
202 Of Aneurijms, Chap. IV. 
 
 furgeon of his acquaintance, in which the 
 bad effects produced by it were fo ftrongly 
 marked, as muft convince any perfon of the 
 general impropriety of fuch a remedy. 
 
 A furgeon having in blood-letting open- 
 ed an artery, the ufual method of tight 
 compreiBon was immediately employed^ 
 By this means the dilcharge of blood ex- 
 ternally was very foon flopped : But fome 
 blood continuing to efcape from the ori- 
 fice in the artery, palTed up towards the 
 fuperior part of the arm, which it filled 
 to fuch a degree, that on the operation for 
 the aneurifm, which was foon found ne- 
 cefFary, being performed, upwards of four 
 pounds of coagulated blood was difcharged 
 from it ; and for this purpofe it became 
 neceiTary to lay the parts open along the 
 whole courfe of the arm *. 
 
 When, again, compreffion has not been 
 applied to fuch tumors, unlefs there is a 
 very unufual degree of foftnefs and laxity 
 in the furrounding parts, the fweiling pro- 
 ceeds to increafe in a more gradual man- 
 ner : 
 
 * Vid. Dionis's Courfe of CHrurgical Operations. 
 
Secfl. L Of Aneurifins. 203 
 
 ner : As it becomes larger, it does not, like 
 the true aneurifm, become much more 
 prominent, but rather fpreads and diiFufes 
 itfelf into the furrounding parts : By de- 
 grees it acquires a very firm confiftence ; 
 and the pulfation, which was at firft con- 
 fiderable, always diminifhes in proportion 
 to this difference of confiftence, and to the 
 increafe which the tumor receives in point 
 of fize ; infomuch, that in large aneurifmal 
 fwellings of this kind, it fometimes hap- 
 pens, that the pulfation of the artery is 
 fcarcely perceptible. 
 
 In the firft ftages of the tumor, if the 
 blood thrown out from the artery lies very 
 deep, the fldn preferves its natural ap- 
 pearance, and does not change its colour 
 till the diforder is much advanced. It fre- 
 quently happens, however, that the blood 
 is at firft thrown out with fo much vio- 
 lence, as to get into immediate conta(5l 
 with the ikin ; and when this occurs, the 
 colour of the parts becomes inftantly livid, 
 as if tending to a ftate of mortification. A 
 pal fphacelus, indeed, has on fome occa- 
 
 fions 
 
>S04 Of Aneurlfms, Chap. IV. 
 
 fions been induced where the extravafation 
 of blood has been confiderable, and where 
 the means belt fuited for its removal have 
 eitlier failed or have been entirely ne* 
 gledled. 
 
 It muft be confidered, however, as a 
 piece of unpardonable negligence, in any 
 pra(fIitioner, to allow a patient, from this 
 caufe, to run that degree of ri£k which al- 
 ways attends mortification ; for the hazard 
 attending the operation of the aneurifm, is 
 in general trifling when compared with 
 the danger accruing from an extenfive 
 gangrene. 
 
 As the tumor in this fpecies of the difeafe 
 proceeds to increafe, the patient, who du- 
 ring the firft ftages of it did not complain 
 of much uneafinefs, is now much diftrefled 
 not only with fevere pains, but with flifF- 
 nefs, want of feeling, and immobility of 
 the whole member : And thefe fymptoms, 
 continuing to augment, if the tumor is 
 not previoufly operated upon, the tegu- 
 ments at lad burft ; and if the artery is of 
 any confiderable fize, and if we have not 
 3 , imme- 
 
Sedl. 1. Of Aneurlfms, 205 
 
 immediate recourfe to efFecflual means for 
 preventing it, death muft for certain en- 
 fue, in confequence of the very profufe he- 
 morrhagy which muft thus be produced. 
 
 Various caufes were enumerated, as be- 
 ing frequently under certain circumftances 
 produdive of the encyfted aneurifm; fome 
 variety occurs too of caufes which termi- 
 nate in the diffufed fpecies of aneurifm. 
 
 I. Violent bodily exertions may be con- 
 fidered as the moft frequent caufe of the 
 rupture of arteries fituated internally ; but 
 as thefe do not properly belong to a work 
 of furgery, we fhall not here enter at any 
 length into their confideration. 
 
 II. The corrofive matter of fores and 
 abfceffes, by entirely deftroying the coats of 
 a contiguous artery, may in this manner 
 be produdlive of the diffufed aneurifm. 
 
 III. The fharp fpiculx of a fradlured 
 bone being puihed into a neighbouring 
 artery, have, on different occafions, pro- 
 duced aneurifm. 
 
 IV. Violent blows have been known to 
 produce aneurifmal fwellings of this kind. 
 
 This, 
 
id6 Of Aneuriffns, Chap. iV. 
 
 This, however, can fcarcely happen in any 
 other licuation than on the head, where the 
 arteries He more expofed than in other 
 parts to the effeds of fuch injuries, by 
 their being here very thinly covered, and 
 from a blow in this fituation adling with 
 great advantage, by falling on the -artery 
 lying almoft in clofe contact with a firm 
 hard body, the cranium. 
 
 V. If the arterial covering of an encyjied 
 arieurifm, fhould ever burft before the ex- 
 ternal teguments of the ttimor, in that cafe 
 the blood contained in it would difFufe it- 
 felf into the contiguous parts ; and in fuch 
 an event, the difeafe would no doubt be- 
 come a real diffufed aneurifm. Such an 
 occurrence, however, we have reafon lo 
 think, very rarely, if ever happens ; for, 
 infhead of the internal coverings of fuch 
 tumors firft breaking, fo far at lead as I 
 have had opportunities of obferving, it is 
 the very reverfe. The fwelling going on 
 tc increafe in a gradual manner, the tegu- 
 ments at laft become fo tenfe and over- 
 flrecched, that they lofe their tone entirely ; 
 I the 
 
Sea. I. OfAneurifins. 20 J 
 
 the fkin becomes foft and oedematous ; oil 
 fome occafions, it comes into a gangrenous 
 date ; and on others, although it retains its 
 natural white colour, yet its ufual powers 
 are as evidently deftroyed as they ever are 
 in the laft ftage of mortification. In this 
 ftate it generally remains for a longer or 
 fhorter fpace of time, according to the 
 ftrength of the arterial pulfation below. 
 At laft, however, the Ikin begins to crack, 
 and a thin ferum oozes out ; the edges of 
 this fmall fifTure in the teguments gradually 
 feparate from one another ; and the con- 
 tents of the tumor having loft a confider- 
 able part of their fupport, the force with 
 which they are impelled, by degrees be- 
 comes too powerful for the remaining co- 
 verings, which accordingly foon burft, fo 
 as to difcharge their contents externally, 
 without producing any efFufion among the 
 neighbouring parts. 
 
 I fliould therefore fufpedl, that authors 
 in general have all along been under fome 
 miftake on this point : The Encyfted, or 
 True Aneurifm, as it is termed, has been 
 
 always 
 
^o8 OfAneurifms^ tlhap. IV; 
 
 always fuppofed in its lafl ftages to burfl 
 internally, and fo to produce the diffufed 
 or falfe fpecies of the difeafe ; from what 
 has been faid, however, there is good reafon 
 to prefume, if ever it does happen, that it 
 is at lead a very rare occurrence. The pro- 
 grefs and termination of the encyfted aneu- 
 rifm, in every cafe I have either feen, or 
 known well authenticated, has been very 
 nearly as we have juft defcribed ; not by 
 the arterial fac firfl: burfling, but by a 
 rupture being produced in the external 
 teguments after they have been greatly 
 over-flretched ; the blood being foon there- 
 after difcharged outwardly, without pro- 
 ducing any efFulion into the furrounding 
 parts. As it has been alleged, however, by 
 very refpe6table authors, that the contrary 
 does now and then happen, and as there is 
 a poflibility of this being the cafe, I could 
 not here avoid confidering it as one of the 
 caufes of diffufed ancurifm. 
 
 VI. The mod frequent caufe, however, of 
 this fpecies of aneurifm, are puncflures with 
 Iharp inflruments, fuch as fwords, cutlafTes, 
 
 and. 
 
Se6i. I. Of Aneurifmso, 569 
 
 and particularly the lancet; which lafl may 
 be confidered as having been produGitve of 
 at lead nine-tenths of all the aoeurifmal 
 fwellings that ever occurred. 
 
 Under one or other of thefe heads, al- 
 moft every cireumftance may be compre- 
 hended, that can ever tend to the produc- 
 tion of fach affedions. 
 
 On many occafions, it has unfortu-. 
 nately happened, that tumors of the aneu- 
 rifmal kind having been miftaken for ab- 
 fceffes and other collections of matter, 
 their contents of courfe have been laid 
 open by incifion. The confequences of fuch 
 pracflice, may be more readily .conceived 
 than defcribed. With a view to prevent 
 fuch dreadful occurrences, it would be a 
 matter of very great importance to prac- 
 titioners, to have fuch a fet of diagnoftie 
 fymptoms of aneurifm pointed out, as 
 would with certainty determine the na- 
 ture of the complaint. In the commence- 
 ment of the diforder, there is in general 
 no great difficulty in determining, as the 
 
 Vol. I. O pulfadoa 
 
210 Of Anetirifms, Chap. IV„ 
 
 pulfadon in the tumor is commonly fo 
 flrong, and other concomitant circutn- 
 ftances tend fo obvioufly to point out the 
 nature of the difeafe, that httle or no 
 doubt refpe<fling it can ever occur; but, 
 in the more advanced ftages of the difeafe, 
 when the fwelUng has become very large, 
 and has loft its pulfation entirely nothing 
 but a very minute attention to the previ- 
 ous hiftory of the cafe can enable us to 
 form a judgment of its nature. 
 
 Thofe fwellings, with which aneurifms 
 are moft likely to be confounded, are, foft 
 encyfted tumors, fcrophulous fwellings, 
 and abfceffes containing either purulent 
 or other matter, fituated either imme- 
 diately above, or fo nearly in contadl with 
 an artery, as to receive the influence of 
 its pulfation; and when any fuch tumor 
 happens to be nearly conne6led with' an 
 artery of confiderable iize, the pulfation 
 communicated to it is frequently found to 
 be fo very ftrong and diftincl, as to ren- 
 der it impolTible from this circumftance 
 
 alone. 
 
Seifl. li- ' Of Aneurifins, jgii" 
 
 alone, to form any jafl idea as to the na- 
 ture of its contents. 
 
 But there is one fymptom which/ when 
 prefent, and when connected with'a ftrong 
 pulfation in the tumor, may always lead 
 us to determine with a great degree of 
 certainty, that thefweliing is of the aneu- 
 rifmal kind; and it is this; the contents 
 ef the tumor being made eafily to difap- 
 pear upon preffiire, at the fame time that 
 they return inflantaneoully on the com- 
 prefTion being removed. But although the 
 f)refence of this circumftance, when con- 
 nected with other charaffceriflic fymptoms 
 of aneurifm, may lead us to conclude, 
 that every tumor is of that nature in which 
 thefe happen to be combined, yet the 
 want of it ought by no means to convince 
 us that it is not of that kind; for it very 
 frequently happens, particularly in the 
 advanced ftages of aneurifms, that their 
 contents become fo firm and compadl 
 that no effedl whatever is produced upon 
 them by preffure. Upon the whole^ there- 
 fore, as in many inftances of chis difeafej- 
 O s no 
 
212 Of Aneurtffns, Chap. iV, 
 
 no certainty whatever can be obtained as 
 to its real nature, in all Inch cafes where 
 there is any confiderable degree of doubt, 
 pradlitioners ought to lay ic down as an 
 eltablilhed rule, to proceed as if the tumor 
 was in reality of the aneurifmal kind. By 
 adhering to this rule, they may perhaps 
 in a few inftances be deterred from open- 
 ing tumors Gff an ordinary nature, which 
 they may afterwards find might have been 
 laid open with fafety; but any leffer in- 
 convenience that may thus be occafioned, 
 will be much more than compenfated, if^ 
 even in a fingle inftance, a furgeon be faved 
 from thofe difagreeable reflexions which 
 he muft experience if he fhoiild have th» 
 misfortune to open an aneurifm inflead of 
 a colledlion of matter. 
 
 But it is in the trunk of the body only, 
 it mufl be obferved, or in the neck, axilla, 
 upper part of the thigh, or groin, that fo 
 much caution in the treatment of tu- 
 mors of this doubtful nature can be ever 
 necefTary. For when (ituated on the un- 
 der part of any of the extremities, or even 
 
 on 
 
Se(5l. I. Of Aneurifms , 21 j 
 
 on any acceflible pare of the head, as in 
 fuch cafes, when the fweliings have pro- 
 ceeded to any confiderable ,iize, the ope- 
 ration for the aneurifm ought always to be 
 performed, fo there can never in fuch cir- 
 cumftances be any impropriety in having 
 recourfe to it ; for if, on laying the tumor 
 open, it is found to be of the aneurifmal 
 kind, we are poflefTed of a very certain 
 method of faving the patient from imme- 
 diate danger, namely, the application of 
 the tourniquet. 
 
 In forming a prognofis in cafes of aneu- 
 rifm, three important circumftances chief- 
 ly require our attention. The manner in 
 which the difeafe appears to have been 
 produced: The part of the body in 
 which the fwelling isfituated: And laftly, 
 the age, and habit of body, of the pa« 
 tient, 
 
 If an aneurifm has come forward in a 
 gradual manner, without any apparent 
 injury having been done to the part, and 
 "Without having fucceeded to any violent 
 bodily exertion ; there will then be great 
 O 3 reafon 
 
a 14 Of Aneurifnu, Chap. IV. 
 
 reafon to fuppofe, that the difeafe depends 
 upon fome paralytic or other general af- 
 fection either of the trunk of the vefiel ia 
 which it occurs, or perhaps of the whole 
 arterial fyftem; fo that no great fuccefs is 
 to be expected from any means to be at- 
 tempted for the patient's relief; for the 
 operation of the aneurifm being performed 
 on the part afFeifled, there would be much 
 reafon 'to fufpe(fl that the famecaufe which 
 originally produced it here will have the 
 efFeiSl of producing fimilar dilatations in 
 other parts of the artery : Whereas, there 
 is great reafon to expedl, if the tumor has 
 evidently fucceeded to a bruife, pundure, 
 or other external accident, that the opera- 
 tion will be attended with complete fuccefs, 
 provided the circulation of the part is not 
 altogether deftroyed by the ligature to be 
 put upon the artery. 
 
 In that fpecies of the diforder we have 
 termed the Varicofe Aneurifm, we may ger 
 nerally venture on a more favourable prog- 
 nofis than in any other kind of aneurifm: 
 For it has been found in diiTerent inftances, 
 
 thai: 
 
Se6l. I . Of Aneurifm s, 215 
 
 that the aneurifmal tamor does not here 
 proceed fo rapidly as in other cafes ; that 
 as foon as it gets to a certain length, it does 
 not afterwards acquire much additional 
 fize ; and that any inconvenience produ- 
 ced by it may be fuftained with tolerable 
 eafe for a great number of years. 
 
 It is in this circumftance alone, we mud 
 
 obferve, that any advantage occurs in the 
 
 treatment of aneurifms from Dr Hunter's 
 
 difcovery of this fpecies of the difeafe : 
 
 And a very important difcovery it is ; for 
 
 by means of it, a patient may be faved, 
 
 not only from a very painful operation, 
 
 but from that great degree of rifl^ which 
 
 mud always attend the deftrucfbion of the 
 
 principal artery of a limb. , In the event of 
 
 a fwelling of this nature arriving at luch 
 
 a fize as to produce much real didrefs, the 
 
 operation ought no doubt to be had re- 
 
 courfe to ; but, fo long as any inconvenience 
 
 arifing from it can be eafily fubmitted to, 
 
 the hazard which almoft always attends 
 
 this operation, and which nothing but ne- 
 
 O 4 ceility 
 
2i6 of Aneurtfms, Chap. IV, 
 
 ccfTity oiiglit to indicate, fliould certainly 
 be avoided*. 
 
 The fituation of the tumor is the next 
 circumilance of importance requiring our 
 attention. When an aneurifmal fwelling 
 is fo fituated, that no ligature or effectual 
 ccmpreilion can be applied for putting a 
 
 ftop 
 
 * In Volume II. Arc. XXXVI. of London Medical 
 Obfcrvatioiis, tM-o cafes are related of the varicofe aneu- 
 rifm, by Dr Hunter. One of them at that thtie was of 
 fourteen years ftanding, and the other had fubfifted 
 for live years, without being produflive of any necef- 
 fity for having recourfe to the, operation. And in 
 Vol, III. of the fame work, Art. XIII. a fimilar cafe of 
 five years duration is related by Dr Cleghorn. 
 
 As it has been alleged by fome pra£litioners, that 
 no advantage refults from the difcovery of this fpe- 
 cies of aneurifm, from their fuppofing that the ufual 
 operation is as necelTary in it as in any other variety 
 of the difeafe ; and as in different inftances the ope- 
 ration has been put in pradlice even in the incipient 
 flages of the diforder, where no real neceflity we think 
 could occur for it \ it therefore becomes a matter 
 of fuch importance as io merit a very attentive exa- 
 mination-, and it is with much fatisfadion that I 
 communicate the following facts, as they tend to 
 eitablifli as a certainty, that in the varicofe aneurifm, 
 
 ' . the 
 
Secfl. I. Of Aneurtfms. 2 if 
 
 ilop to the circulation in the part, if the 
 artery be large, there would be the utmofl 
 
 hazard 
 
 tlie ufual operation of obliterating the cavity of the 
 artery, is feldom, if ever, neceflary. 
 
 In a letter I am favoured with from Dr Hunter, he 
 fays, " The Lady in whom I firft obferved the vari- 
 cofe aneurlfm is now living at Bath in good health ; 
 and the arm is in no fenfe worfe, although it is now 
 thirty-five years fmce fhe received the injury. " And 
 the Docler farther obferves, that he never heard of 
 the operation being performed for the varicofe aneu- 
 jrifrn that was known to be fuch. 
 
 In a letter from Dr Wilham Cleghorn of Dublin, I 
 am informed, that the cafe of varicofe aneurifm above- 
 mentioned, as related in the 3d Volume of London 
 Medical Obfervations, remains nearly in the fame ftate 
 as at the time that account of it was made out, which 
 was at leaft twenty years ago; only that the veins are 
 rather more enlarged. The patient recovered, and 
 the limb became nearly as (Irong and ferviceabi ; as 
 the other. The man has all along continued his bu- 
 {inefs of flroemaker, and has lately recovered from a 
 fprain in the afFedled arm, which he received in lift- 
 ing a heavy burden. 
 
 In a letter from Mr Pott, whofe opportunities for ob- 
 fervaticn are great, he fays that he has m^et with three 
 different inftances of this fpecies of aneurifm, and that 
 the Qper?.tion never became neceflary in any of them. 
 
 Among 
 
tiS OfAneurl/ms, Chap. IV, 
 
 hazard in opening it; as the patient, in all 
 probability, would lofe more blood thau 
 his ftrength could bear, before the artery 
 could be lecured. In aneurifms fo (ituated, 
 therefore, particularly on any part of the 
 trunk of the body, on the neck, axilla, or 
 groin, there can never be any good foun- 
 dation for a favourable prognofis. On the 
 contrary, indeed, in fuch fituations, the 
 greateft danger is always to be apprehend- 
 ed: For the force of the arterial pulfation 
 .will at lad certainly overcome the refin- 
 ance of the coats with which the tumor is 
 furrounded ; and in fuch an event, the mofl: 
 fatal confequences are to be apprehended. 
 
 In 
 
 Among other inftances ofvaricofe aneurifm which 
 have appeared here, a young man from Paifley, who 
 had the misfortune to meet with it feveral years ago, 
 was examined by different furgeons of this place. 
 The difeafe was very clearly marked, and no operation 
 was advifed. In a letter from Mr Hamilton pro- 
 feflbr of Anatomy in Glafgow, I am inrormed, that 
 this man is now ferving in the Navy, where he underr 
 goes great fatigue without any 'nconvenience frona 
 the aneurifm, although it is now of thirteen years 
 .ftandijig. 
 
Stifl. I. Of Aneurifms. 219 
 
 In the upper parts of any of the extre- 
 mities, too, where all the arteries of the 
 limb are centered in one common trunk, 
 the fuccefs of the operation for the aneu- 
 rifm muft always be doubtful. But al- 
 though this is undoubtedly the cafe in the 
 fuperior parts of the extremities, yet in 
 lower fituations of the fame parts, even the 
 principal artery of the limb may be ope- 
 rated upon with a very fair profpedl of 
 fuccefs ; for after the great artery of a mem- 
 ber has crept along the upper part of it, 
 a number of fmall branches are always 
 fent out, which anaftomozing " not only 
 with iimilar branches below, but by their 
 means with the under part of the large ar- 
 tery itfelf, thefe, in the event of the com- 
 mon trunk from whence they fprung be- 
 ing deftroyed, come to dilate to fuch an 
 extent as to carry on the circulation in the 
 inferior part of the limb much more com- 
 pletely than could a priori be expedled. 
 We would not naturally fuppofe, aft£r the 
 principal artery of a part has beon obli- 
 terated, that the circulation would there 
 
 be 
 
2 2 o Of Aneurlfms, Chap . IV. 
 
 be afterwards carried on with any tolerable 
 degree of force ; and yet numberlefs in- 
 ftances have occurred of the large brachial 
 artery being completely deftroyed by liga- 
 ture, without being produ<ftive of much 
 inconvenience to the parts below ; and the 
 fame circumftance has alfo happened, 
 where the operation for the aneurifm has 
 been performed on the trunk of the great 
 femoral artery *. 
 
 Frona what has been faid, therefore, it 
 
 mufl 
 
 * In one cafe, the operation for the aneurifm was 
 performed with the moft complete fuccefs, on the 
 trui"fk of the femoral artery, about two hand-breadths 
 from the groin, by the late Wr Hamilton profeflbr of 
 Anatomy in Glafgow. And what rendered this cafe 
 more remarkable, was, that after the trunk of the large 
 artery was fecured by the ligatures, it was neceflary to 
 perform the operation again upon a fmall branch of 
 an artery which had been wounded, even farther up 
 than the principal trunk. 
 
 For fome time after the operation the limb remained 
 
 colder than the other, and it was upwards of a week 
 
 before any pulfation could be felt in the artery at the 
 
 ankle. In two months from the operation, the wound 
 
 ~was completely healedj and the circulation and heat 
 
 returned j 
 
Bed. I. Of Aneurifms, 2^1 
 
 muft appear, that when an aneurifm is fo 
 (ituated, that compreilion cannot be applied 
 fo as to fecure the patient from the lofs of 
 much blood when the artery is laid open* 
 the operation fhould not be attempted j and 
 in fuch cafes the prognofis ought certainly 
 
 to 
 
 returned ; and in a fliort time thereafter, the patient 
 had fo far recovered the ufe of his limb, as to be able 
 to take very violent exercife. 
 
 Thefe ^particulars I thought It right to communi- 
 cate, as the cafe of this patient is on^ of a very few 
 well authenticated inftances, of this operation having 
 been attempted on the femoral artery fo near to its 
 origin; and the fuccefs attending it furely points out 
 the propriety of having recourfe to the operation, in 
 every aneurifm of thefe parts that does not evidently 
 arife from a general debility of the coats of th€ artery. 
 And as I am favoured with this account of the cafe 
 from the prefent profeflbr of Anatomy in Glafgow, 
 Mr Hamilton, fon to the lats profeffor, its authenti- 
 city may be depended on. 
 
 In Vol. III. Article XII. of the London Medical 
 Obfervations, there is another infbnce related of the 
 operation for the aneurifm having been performed on 
 the trunk of the femoral artery, by Mr Burchal fur- 
 geon in Manchefter ; the patient recovered, and the 
 limb became nearly as ftrong and as ferviceable as die 
 other. 
 
'S22 Of Ancurifm's, Chap. IV. 
 
 to be very unfavourable. And on the 
 contrary, whenever an aneurifm, produced 
 by external violence, is feared on any of 
 the extremities, where we are fure of com- 
 manding the circulation, the operation 
 ought always to be undertaken, as foon aSj 
 fronfj appearances, there is the leaft reafon 
 to fafpect that the tumor if left to itfelf 
 might buril fo as to endanger the life of 
 the patient. 
 
 The fuccefs of this operation, depending 
 in a great degree upon the probable chance 
 there is for the circulation afterwards go- 
 ing on in the under part of the member, 
 our prognofis, in every cafe of aneurifm, 
 oughr, Citteru paribus^ to be more or lels 
 favourable, according as the diforder is 
 feated higher or lower on the different ex- 
 tremities : For the rilk of the circulation 
 being hurt by it, is always in proportion 
 to the height of the tumor ; according as 
 it is higher or lower, this rifk is always 
 increafed or diminifhed. 
 
 Bat laflly, whether an aneurifm has been 
 produced by an external injury, or by the 
 
Sedt. I. Of Atieurifrhu 2 2| 
 
 efFedls of internal difeafe, and whatever 
 may be its fituation, the habit of body and 
 age of the patient ought to have a confi-. 
 derable influence, in determining the opi- 
 nion of praclitioners as to the effcfls to be 
 expeded from the operation. In no opera- 
 tion, indeed, that we are acquainted with, 
 are theadvantages derived from health and 
 youth more confpicuous than in this ; for 
 in the earlier periods of life, all the fofter 
 parts accommodate themfelves much more 
 readily to the circumflances attending any 
 great change that may take place, than they 
 ever do in the more advanced ftages of life: 
 In old age, all the animal fibres have acqui- 
 red fuch a degree of firmnefs and folidity, 
 as to be rendered almoil incapable of diften- 
 tion; and this feems to be particularly the 
 cafe with the arterial fyftem, fome parts of 
 which are often known to proceed even to 
 a ftate of oflification ; So that at this period 
 of life, we may readily fuppofe the fmaller 
 arteries to be rendered altogether incapable 
 of that degree of diftention neceiTary for 
 fupplying the wane of the principal artery 
 
 of 
 
^24 OfAneurlfmu Chap. IV. 
 
 of a part, and which in the more early 
 periods of life they might with great eafe 
 have admitted of. 
 
 This operation having been performed 
 with various degrees of fuGcefs, even where 
 the aneurifmal tumors were apparently in 
 every refpecl {iinilar both as to fituacion 
 and other circumflances, various reafons 
 have been fuggefted to account for this. 
 With fome the operation has fucceeded, 
 even under circumflances apparently more 
 ■unfavourable, than with others where it 
 failed. Thus it has been known to an- 
 fwer, as we have lately remarked, feveral 
 inches above the knee, when the trunk of 
 the femoral artery was for certain taken 
 up by the ligature ; and in others, it has 
 failed when done in the ham : That is, in 
 the former, the circulation in the under 
 part of the leg was ftill preferved, and the 
 patients recovered ; while in the latter, 
 where fuccefs might more readily have 
 been expected, the limbs remained cold 
 after the operation, no return of circula- 
 tion took place, mortification at laft was 
 induced, and the patients died. 
 
 X Fronri 
 
Sed. L QfAneiirifms, 22 § 
 
 Fom this variety of fuccefs attending- itj 
 we find very contradidlory opinions held 
 forth refpeding this operation. While one 
 condemns it as being never produ(5live of 
 any good, except in the very extreme pares 
 of a member; others afTert, that even the 
 largeft artery of a limb may be operated 
 upon with great probability of fuccefs. 
 
 This contrariety of opinion, however, 
 tnay, I think, be eafily explained, by v/hat 
 has been faid above refpeding the age and 
 habit of body of thofe on whom the ope- 
 ration is performed ; for, to the diiferenC 
 powers of diftention with which the arte- 
 rial fyftem is endowed at different periods 
 of life, the good or bad fuccefs attend- 
 ing it may with fufficient reafon be attri- 
 buted: So that, although in an old in- 
 firm perfon, it may have been found to 
 fail perhaps in the under part of the leg 
 or arm, this fhould by no means deter us 
 from having recourfe to it, even in much 
 higher fituacions, by patients that are young 
 and healthy. 
 
 Having thus confidered the ufual appear- 
 
 "VoL. L P ances 
 
2 26 Of Aneurifms, Chap. iV. 
 
 ances and caufes of aneurifm, together with 
 the grounds upon which a jufl prognofis 
 is to be formed, we Ihall now proceed to 
 the method of cure. 
 
 SECTION II. 
 
 Of the Treatment of Aneurifms. 
 
 TN every cafe of aneurifm the ufe of pref- 
 fure has been indifcriminately recom- 
 mended, not only in the incipient period of 
 the difeafcj but even in its more advanced 
 ftages. In a former chapter on Blood- letting, 
 as well as in fome parts of this, different 
 opportunities occurred for introducing the 
 confideration of this fubjed: To thefe we 
 mufl now refer J and fliall at prefent at- 
 tend to fuch points only as were not before 
 fo particularly entered into. 
 
 In the diftufed or falfe aneurifm pref- 
 fure'has beenuniverfally advifed, not only 
 with a view to diffipate the fwelling al- 
 ready induced, but in order to produce a 
 reunion of the wound in the artery : We 
 have already made it appear, however, as 
 pi'elTure in fuch cafes cannot be applied to 
 
 the 
 
Sedl. II. Of Anetirifms, iij 
 
 tlie artery alone, without at the fame time 
 afFe(5ling the .veins ; and as this circum- 
 ftance^ by producing an increafed reiill- 
 (lance to the arterial pulfations, muft un- 
 doubtedly force an additional quantity of 
 blood to the orifice in the arterv, that 
 therefore no advantage is to be expecled 
 from it; but, on the contrary, that on 
 many occafions there is reafon to fuppofe it 
 has been productive of bad confequences. 
 
 But although prelTure ought never to be 
 attempted in any period of the difFufed 
 aneurifm, yet in forae ftages of the other 
 ipecies of the difeafe, it may be often ap- 
 plied with advantage. 
 
 In the early flages of encyiled aneurifm, 
 while the blood can be yecprefled entirely 
 out of the fac into the artery, it often hap- 
 pens, by the ufe of a bandage of foft and 
 fomewhat elaftic materials, properly fitted to 
 thepart, that much may be done in prevent- 
 ing the fwelling from receiving any degree 
 of increafe ; and on fome occalions, by the 
 continued fupport thus given to the weaken- 
 ed artery, complete cures have been at lad 
 P 2 obtained 
 
228^^ OfAneiinfms, Ghap. IV, 
 
 obtained. la all fuch cafes, therefore, par- 
 ticularly in every inftance of the varicofe 
 aneurifm, which we have already endea- 
 voured to fhow can very feldom require the 
 ufual operation, much advantage may be 
 cxpedled from moderate prefTure. 
 
 But although prellure to a certain degree 
 has frequently in cafes of encyfted aneu- 
 jifm proved very ufeful, it ought never to- 
 be carried to any great length ; for tight 
 bandages in all fuch afFecftions, by produ- 
 cing an immoderate degree of rea(5lion ia 
 the containing parts to which they are ap- 
 plied, inft^ad of anfwering the purpofe for 
 which they were intended, have evidently 
 the contrary effed. Moderate compref- 
 iion, therefore, is more eligible than a great 
 degree of it ; and indeed the greateft length 
 to which prelTure in fuch cafes ought to go,, 
 ihould be, to ferve as an eafy fupport to the 
 parts alleded, and no farther. 
 
 While at the fame time we have recourfe 
 to this remedy of comprefllon, other means 
 ought not to be omitted: The patient 
 fliouldbe kept upon a low dietj whenne- 
 
 ceffjiry. 
 
Sec^. II. Of Aneurifms. 22-9 
 
 cefTary, fome blood fhould be evacuated ; 
 the bowels fhould be kept lax; and all vio- 
 lent exercife, particularly of the part af- 
 fe(5led, fhould be carefully guarded againft. 
 In the latter ftages of aneurifm, when much 
 lenlion and pain are induced, opiates are 
 found very ufeful; and in many fuch ail- 
 ments they are the only clafs of remedies 
 from which any relief is obtained. 
 
 The treatment here recommended ap- 
 plies to every aneurifm not intended to be 
 operated upon; but it is particularly proper 
 in all fwellings of this kind lituated on the 
 trunk of the body and other parts where 
 the operation is inadmiffible. In fuch fi- 
 tuations, indeed, an eafy fupport by means 
 of gentle comprefHon, a low diet in order 
 to prevent a plethoric date of the vefTels ; 
 repeated blood-lettings when plethora ac- 
 tually exills ; a total abflinence from exer- 
 cife; and the ufe of opiates when indicated 
 by pain; are the only remedies from which 
 much benefit is to be expecled. 
 
 Having thus pointed out the different: 
 
 r£pe4Jes to be employed Vv^herc the opera- 
 
 F 4 tioa 
 
230 of Aneurlfms. Chap. IV. 
 
 tion is either not confidered as proper, or 
 where it is rendered inadmifiible by theii- 
 tuation of the fwelling, we Tnall now pro- 
 ceed to defcribe the operation itfelf, on the 
 fuppofiiion of its having become necefTary, 
 eitjier when the means recommended for 
 the previous treatment of thediforder have 
 failed, or when the tumor has made too. 
 great progrefs before proper affiftance was 
 procured. 
 
 The firfl; ilep in thia operation ought to 
 be, to obtain a full command of the cir- 
 culation in the inferior part of the member 
 by means of the tourniquet applied above. 
 
 This being effedled, the patient fhould be 
 fo placed, that the difeafed limb, on being 
 ftrctched on a table, is found to be of a 
 proper height for the furgeon, who, as the 
 operation is generally tedious, ought to be 
 feated. The limb being in this iituation 
 properly fecured by an aiTiftant, the ope- 
 rator is now v/ith a fcalpel to make an in- 
 cifion through the &in and cellular fub- 
 ifance, along the whole courfe of the tu- 
 mor ; ^ and as it is a matter of much impor- 
 tance to have a fuiEci^ent command of fpace 
 
 for 
 
Sedl. 11. Of Aneurifms, 23 j 
 
 for the remaining parts of the operation, 
 it is even of ufe to carry this external in- 
 cifion about half an inch both above and 
 below?the extremities of the fwellmg : No 
 mifchief can occur from the iirO: incifion 
 being made very free and extenfive; and I 
 have feen different inftances of the opera- 
 tor being much embarraffed in the fabfe- 
 quent fleps of the operation, by too much 
 timidity or perhaps ill-judged lenity in this 
 part of it. 
 
 This being done, the ordinary method is, 
 to proceed in a very flow, cautious manner, 
 diire<5ling away one layer of the membrane 
 after another, till the artery itfelf is laid 
 bare. In this manner the operation is al- 
 ways rendered exceedingly tedious, as the 
 thicknefs of parts with which the artery is 
 found covered, is often really aftonifhing, 
 by one layer of a membranous fubftance 
 having been formed after another, from 
 the coagulable lymph of the blood con- 
 tained in the tumor. In reality, hovv'ever, 
 there is no neceihty for this degree of 
 caution, as the operation may in the foL- 
 b.w;ng manner be equally well performed 
 
 5 
 
 P A ill 
 
2^2 Of Aneur'ifms, Chap . IV, 
 
 in a much (honer fpace of time, and with 
 much lef^ pain to the patient. 
 
 As foon as the external incifion has been 
 made in the manner direcled, fo as to divide 
 the ikin and cellular fubftance, all the ef- 
 fufed blocd ought to be wiped ofFby means 
 of a fpoi.ge ; and the fofteft part of the 
 tumor being difcovered, an opening ought 
 there to be made into it with a lancet, 
 large enough for admitting a finger of the 
 operator's left hand. This being done, 
 and the finger introduced into the cavity of 
 the tumor, it is now to be laid open from 
 one extremity to the other, by running a 
 blunt- pointed biftoury along the finger 
 from below upwards, and afterwards from 
 above downwards, fo as to lay the v»^hole 
 cavity fairly open. In Plate VII. fig. r. 
 there is an exacft reprefentation of this bi- 
 floury, with a curve much lefs than ufual, 
 as a very flight concavity anfwers every 
 purpofe, and cuts moreeafily than a great- 
 er degree of curvature. 
 
 The cavity of the tumor being thus laid 
 ffeely opeUj all the coagulated blood is 
 
 nQV7 
 
Scifl. 11. Of Aneurifrns, 235 
 
 now to be taken out : For which purpofe^ 
 a number of inflruments, particularly 
 fcoops, have been invented by diiFerent 
 operators ; but no inftrument anfwers this 
 intention fo efFe^uaHy, and with fb much 
 eafe to the patient, as the fingers of the 
 operator ; who having in this manner re- 
 moved all the coagulated blood, together 
 with thofe tough membranous filaments 
 commonly found here, the cavity or the 
 tumor is now to be made quite dry, and 
 cleared of the blood which on the firft 
 opening of the fv/elling is difcharged into 
 k from the veins in the inferior part of the 
 memiber ; and this being efFeclualiy ac- 
 complifhed, the tourniquet mud be made 
 perfe(5lly ilack and tTi^y^ in order to difcover 
 not only the artery itfeif, but the opening 
 into it from whence the blood collected iii 
 the tumor has been all along difcharged. 
 This being done, the next point to be 
 determined, is, the manner of prevent- 
 ing any farther etfuiion of blood into 
 the aneurifmal iuc. Various means have 
 \}t^n propofed for accomplifliing this ; 
 
 buc 
 
334 Of Aneurifms, Chap. IV, 
 
 but the efFe(5ts of all of them may be 
 comprehended under the three following 
 heads. 
 
 I. The efFecls of ligature upon a large 
 artery, having infomeinftances occafioned 
 the lofs of the inferior part of the member, 
 it was long ago propofed, that fo foon as 
 the opening into the artery has been dif- 
 covered, inftead of applying a ligature 
 round it, which for certain is to obliterate 
 its^ cavity entirely, a piece of agaric, vi- 
 triol, alum, or any other aftringent fub- 
 ftance, fhould be applied to the orifice, in 
 order if poflible to produce a reunion of 
 its fides. 
 
 II. Upon the fame principle with the 
 preceding, viz. that of flill preferving the 
 circulation in the artery, it was feveral 
 years ago propofed by an eminent furgeon 
 of Newcaftle, Mr Lambert, that the orifice 
 in the artery fhould be fecured by means 
 of the twifted future. A fmall needle 
 being puflied through the edges of the 
 wound, they are then directed to be drawn 
 together by a thread properly twifted 
 
 3 roun^ 
 
Se£l. II. Of Aneurzfm^, 235 
 
 round the needle, in the manner formerly 
 advifed when treating of futures *. 
 
 Strong objedions, however, occur to 
 both of thefe methods. In the firfl place, 
 no aftringent application with which we 
 are acquainted, is poffeffed of fuch powers 
 as to deferve much confidence ; for, al- 
 though different articles of this kind have 
 on various occafions proved a means of 
 putting a temporary ftop to hemorrhagies, 
 yet there are very few inftances properly 
 authenticated, of their having produced 
 any permanent advantage. In almoft 
 every inflance in which they have been 
 iifed, the hemorrhagy has recurred again 
 and again, fo as to prove very diftreffing, 
 not only to the patient, but to the practi- 
 tioner in attendance ; fo that from this 
 want of fuccefs, little or no attention is 
 now paid to remedies of this kind in ordi- 
 nary pra(5lice. 
 
 With regard to Mr Lambert's method 
 of fxitching the orifice in the art^y, it is 
 
 certainly 
 
 * Vide London Medical Obfervations, Vol.il. Aj. 
 
23^ Of Aneurtfms^ Chap. IV, 
 
 certaialy a very ingenious propofal, and 
 would in all probability, at lead in moft 
 inftances, prove an effecflual (lop to all 
 farther difchargc of blood ; but as it has 
 hitherto, at lead fo far as I have heard, 
 been only attempted in one inflance, far- 
 ther experience of its eiFe£ls is necefTary 
 before it can with propriety be either 
 rejecfied or approved. But if in fuch 
 a matter reafoning may be indulged, 
 we would beg leave to obferve, that two 
 material objeclions occur to this prac- 
 tice. One is, that in the operation for 
 the aneurifm, in almoft every initance, a 
 very few only accepted, the artery lies at 
 the back part of the tumor ; (b that when 
 all the colledled blood is removed, there is 
 fuch a depth of wound, that it muft be 
 always a very difficult matter, and en 
 many occaiions quite impratflicable, to 
 perform this nice operation upon the ar- 
 tery, with that attention and exaiflnefs^ 
 which, in order to infure fuccefs, it cer- 
 tainly requires. It has now and then hap- 
 pened indeed, that in this operation the 
 
 artery 
 
Se£l, II. Of Amtirlfmf„ Q^f 
 
 artery has been found to ]?e on the anterior 
 part of tke tumor, and in fuch a fituation^ 
 the wound in it would no doubt prgve ag- 
 eefFible enough. This, however, is a very 
 rare occurrence, as in alnjofl every inftance 
 of difFufcd aneurifm the artery lies at the 
 very bottom of the tumor, the bloodl 
 being colledled between it ^nd the com- 
 mon teguments ; and accordingly I have 
 feen feveral inftances of tliis diforder, in 
 which, after the tumor was laid freely 
 open, the artery was found to lie fo deep 
 as would have rendered it quite impoflible 
 to perform this operation. 
 
 But there is another very material oI>- 
 jedlion which a priori evidently occurs t» 
 the pradlice recommended by Mr Lam- 
 bert. By introducing a needle thro' the 
 fides of the orifice, and drawing thefe to- 
 gether by a ligature, the cavity of the ar- 
 tery muft undoubtedly be at that poinc 
 much diminifhed. Indeed Mr Lambert, itk 
 his account of the cafe in which this ope-^ 
 ration was performed, acknowledges that' 
 the diameter of the artery was thereby di- 
 
 minifh€4* 
 
5i3S ^ O/Jneurifms. Chap. iV". 
 
 xninifhed. Now, the paflage of the blood 
 being thus contraded at one point, the 
 impulfe vipon that particular part mud be 
 Very confiderable : So that the very remedy 
 employed for the cure of one fpecies of 
 aneurifm, will in all probability prove a 
 very powerful agent in inducing another ; 
 for the blood being thus obftrudlcd in its 
 ufual courfe, there will be no fmall dan^ 
 ger incurred, of a dilatation being produced 
 immediately above this preternatural ftrlc- 
 ture. 
 
 I muft fairly acknowledge, however, that 
 a]l I have advanced, proceeds from reafon- 
 ing alone, and is not as yet fupported by 
 experience. But, if farther trials of this 
 operation tend to fhow that the objecSlions 
 now ftated againft it are not well founded^ 
 no perfon whatever will be more ready 
 than 1 fliall be in adopting it ; for, if thefe 
 bbjedidns were removed, this operation, 
 as propofed by Mr Lambert, I fhould con- 
 fider as defer ving to be ranked among the 
 moft important improvements which in 
 modern times furgery has acquired. In- 
 
 the 
 
Sedl.ll. Of Amiirifms, i^T) 
 
 the treatment of aneurifm by the common 
 operation, if the principal artery of a limb 
 is concerned, fome ri£k is always incurred, 
 hot only of injuring the parts below in a 
 mofl material manner, but even of deftroy- 
 ing them entirely, by depriving them of 
 the quantity of blood necefTary for their 
 fupport. Now, by Mr Lambert's im- 
 provement, an efFeclual flop is put to the 
 farther evacuation of blood, while at the 
 fame time the circulation in the difeafed 
 artery is flill preferved ; fo that if farther 
 experience of its efFedts fhali fhow that the 
 objedlions we have ventured to bring againft 
 it are not well founded, it will defervedly 
 be admitted as a very material improve- 
 ment in the treatment of this ipecies of 
 aneurifm. ' 
 
 III. Neither of the methods we have yet 
 been confidering, being found eligible 
 for fecuring the orifice in the artery, we 
 {hall now proceed to defcribe the ordi- 
 nary manner of performing this operation, 
 which confifts in obliterating the arterial 
 
 cavity 
 
^40' Of /incur ifvds. Chsp. IV, 
 
 cavity entirely, by means of ligatures; and 
 t;he method of doing it is this. 
 
 The artery being laid bare in the man- 
 lier direfted, and all the coagulated blood 
 being carefully removed fromthe cavity of 
 the tumor, on the tourniquet being now 
 flackened fo as to bring the orifice in the 
 artery into view, a fmall probe is to be 
 introduofd at the opening, with a view 
 to raife the artery from the neighbouriing 
 parts, fo as that the furgeon may be en- 
 abled with certainty to pafs a ligature 
 round it without comprehending the con- 
 tiguous nerves, which in general run very 
 near to the large blood-veflels of a limb. 
 By this precaution, the nerves may be 
 always avoided ; and by doing fo, a greac 
 deal of mifchief may be prevented, which 
 otherwife in all probability might fuper^ 
 vene. When the diforder is fituated either 
 in the ham, or in the ufual place of blood- 
 letting in the arm, bending the joints of 
 the knee or of the elbow, as it relaxes 
 the artery a little, renders this part of 
 \}(\^ operation more eaflly affected, thaa 
 2 when 
 
Sed. IL OfAneurlfms, 241 
 
 ■when the limbs are kept fully extend- 
 ed. 
 
 The artery being thus gently feparated 
 from the contiguous parts, a firm, broad, 
 waxed ligature mult be pafTed round it, 
 ibout the eighth part of an inch above 
 the orifice, and another maft in the fame 
 manner be introduced at the fame diftance 
 below it. Much harm, I am convinced, 
 has been done by palTing the ligature ^o 
 far diftant from the orifice as is commonly 
 pradifed ; for the rilk of lofing the be- 
 nefit of anaftomofing branches will be al- 
 ways increafed in proportion to the extent 
 of artery included between the ligatures. 
 
 The eafieft method of introducing the 
 ligatures, is by means of a blunt curved 
 needle j and the form reprefented in PI. V. 
 fig. 2. will be found more convenient for 
 this purpofe than any other. An ordinary 
 fharp needle is commonly made ufe of for 
 this purpofe ; but it does not anfwer the 
 intention fo well as the one here recom- 
 mended : By the fliarpnefs of its points it 
 is apt to injure the contiguous parts ; and 
 
 Vol. I. O when 
 
242 Of Aneiirifms, Chap. iV. 
 
 when the common crooked needle is ufed 
 with a fharp edge on its concave fide, there 
 inuft even be fome rifk of its wounding 
 the under part of the artery, as in this fi- 
 tuation it cannot be introduced without 
 making part of the needle pafs quite in 
 conta6t with the coats of the artery. The 
 blunt needle is not liable to either of 
 thefe objed\ions ; and befides, when of the 
 form here reprefented, it is more eafily in- 
 troduced than any of the needles com- 
 monly ufed in this operation. 
 
 The ligatures being both pafTed in the 
 manner diredled, the upper one is now to 
 be tied with a firmnefs fufiicient for com- 
 prefling the fides of the artery. The direc- 
 tions formerly given for forming the knot 
 upon bleeding-vefTels in other parts, will 
 apply with equal propriety here : The ends 
 of the ligature ought by all means to be 
 twice pafTed through theiirft noore,and this 
 fhould again be farther fecured by a fingle 
 knot made above it. By many writers on 
 this fubject, a fmall bolfler of linen is or- 
 dered to be inferced between the artery 
 
 and 
 
Seel. II. Of Aneurifnii. ^43 
 
 and the knot, in order to prevent the ar- 
 tery from being cut by it. This, however^ 
 is a very unnecefTary precaution ; for if the 
 whole artery is not furrounded with the 
 bolfter, it will be juft as liable to be 
 cut by the ligature at any other part as 
 where the knot is fixed : And befides, as 
 we have already very fully remarked, there 
 is no occafion whatever for making the liga- 
 ture fo tight on arteries as to fun anyrifk of 
 dividing therii ; a much lefs degree of pref- 
 fure than is either commonly applied, or 
 could have any influence in hurting themj 
 being fully fufficient for compreiling them 
 in the mofl effedlual manner. 
 
 The upper ligature being thus finifhed^ 
 before the knot is pafled upon the other 
 below the orifice, the tourniquet ought to 
 be untwifted, in order to fee whether any 
 blood is now difcharged by the wound in 
 the artery or not. If blood flows in any 
 confiderable quantity, it affords a pleafanc 
 profped of the fuccefs with which the ope- 
 ration will in all probability be attended, 
 as it] clearly fhows, that the anallomofing 
 Qj2 branches 
 
^44 Of Aneurifms, Ch^p.tV* 
 
 branches from the fuperior part of the ar- 
 tery are confiderable enough for carrying 
 on at leafl: a tolerable degree of circulation 
 in the under part of the member. At the 
 fame time, however, although blood (hould 
 not be difcharged at this time by the ori- 
 fice, we are by no means, from this circum- 
 flance alone, to defpair of fuccefs ; for it 
 frequently happens that this operation fuc- 
 ceeds in a very effedlual manner, although 
 no blood whatever is difcharged on the 
 trial now recommended. 
 
 But whether any blood ihould be dif- 
 charged by this trial or not, we are not to 
 reft fatisfied with one ligature ; for unlefs 
 the ligature below the orifice be alfo tied, 
 there is always a rifk, on the return of cir- 
 culation to the under part of the artery, 
 of blood pafling out at the orifice : This 
 precaution, therefore, fhould never be omit- 
 ted ; it is eafily done, and it renders the pa- 
 tient quite fecure againft all farther eva- 
 cuation of blood by the orifice. After the 
 knots have been put upon the ligatures, thefe 
 fhould be cut of fuch a length that their 
 
 ends 
 
Sedl. II. OfJfteur'yms, 245 
 
 ends may He fully out over the edges of 
 the wound, fo that when neceffary they 
 may be more eafily withdrawn. 
 
 By way of greater fecurity in this ope- 
 ration, ic has been advifed to infert other 
 two ligatures quite contiguous to the for-!" 
 mer, and to leave them untied, fo that if 
 any of the others fhould happen to fail its 
 place may be immediately fupplied. 
 
 There is not, however, any necefTity for 
 this precaution, for, if the firft ligatures are 
 properly applied, there can be no doubt of 
 their anfwering the purpofe ; and in cafe 
 either one or both of them (hould give 
 way, they can be very eafily renewed : 
 In the mean time, too, the patient is ren- 
 dered fafe againft any fudden lofs of blood 
 by the tourniquet being left loofe upon 
 the upper part of the member, which it 
 ought by all means to be for feveral days 
 after the operation, fo that, in the event 
 of blood burfting from the wound, it may 
 be fecured by means of it, much more rea- 
 dily than if it depended on the tying of a 
 ligature. 
 
246 Of Aneurlfim, Chap. IV. 
 
 The ligatures being both finifhed in the 
 manner direded, the tourniquet is now to 
 be made quite loofe; and if no blood is 
 difcharged at the orifice in the artery, we 
 may then reft fatisfied that the operation 
 is fo far properly completed. 
 
 The wound is now to be lightly covered 
 with foft lint, with a pledget of any emol- 
 lient ointment over the whole ; and a com- 
 prefs of linen being applied over the dref^ 
 iings, all the bandage in any degree requi- 
 lite, is, two or three turns of a roller above, 
 tmd as many below the centre of the woundj 
 making it prefs with no more tightnefs 
 than is abfolutely necefTary for retaining the 
 applications we have juft now mentioned. 
 
 The patient being now put into bed, 
 the member fliould be laid in a relaxed 
 pofture upon a pillow, and ought to be fo 
 placed as to create the leaft poflible uneafi- 
 r.-cfs from the pofture in which it is laid. 
 
 As the operation for the aneurifm is al- 
 ways tedious, and produces much pain and 
 irritation, a full dofe of laudanum fliould 
 be given immediately on the patient being 
 
 got 
 
Sed. II. , Of Aneunfms, 247 
 
 got into bed. In order to dlminifh fenfi- 
 bility during fome of the more capital ope- 
 rations, I have made different trials of opi- 
 ates given about an hour before the ope- 
 ration : On fome occafions, this proved 
 evidently very ufeful ; but on others, it 
 feemed to do harm ; particularly in weak, 
 nervous conflitutions, in which with any 
 dofes I ever ventured upon, the patients 
 appeared to be rendered more irritable 
 and more fufceptible of pain, than if no 
 opiate had been given. Immediately after 
 this operation) however, an opiate ought 
 to be exhibited, and repeated occafionally 
 according to the degrees of pain and reft- 
 leffiiefs. 
 
 In fome few cafes of aneurifm it has hap- 
 pened, that the pulfe in the under part of 
 the member has been perceptible immedi- 
 ately after the operation. This, however, is 
 a very rare occurrence : For as this diforder 
 is feldom met with in any other part than 
 at the joint of the elbow as a confequence of 
 blood-letting, and as it rarely happens that 
 the brachial artery divides till it pafTes an 
 0^4 , inch 
 
248 Of Aneurlfms, Chap. IV. 
 
 inch or two below that place, the trunk 
 of this artery is therefore mofl frequently 
 wounded; and when accordingly the liga- 
 ture in this operation is made to obftrudl 
 the pafTage of almoft the whole blood that 
 went to the under part of the arm, there 
 cannot be the leafl: reafon to expecl any 
 pulfation at the wrift, till in a gradual 
 manner the anaflomoling branches of the 
 artery have become fo much enlarged, as 
 to tranfmit fuch a quantity of blood to the 
 inferior part of the member, as is fufficient 
 for adling as a flimulus to the larger 
 branches of the artery. 
 
 Immediately after the operation, the par 
 tient complains of an unufual numbnefs- 
 or want of feeling in the whole member ; 
 and as it generally for a few hours be- 
 comes cold, it is therefore right to keep it 
 properly covered with warm fofc flannel ; 
 and in order to ferveas a gentle flimulus to 
 the parts below, moderate fridions appear 
 to be of ufe. In the fpace of ten or twelve 
 Lours from the operation, although the 
 fiUtnbnefs fhill continues, the heat of th« 
 
 parts 
 
Sed. II. OfAneuriJms, 54^ 
 
 parts generally begins to return ; and it 
 frequently happens in the courfe of a few 
 hours more, that all the inferior part of 
 the member becomes even precernaturally 
 warm. 
 
 Although phyfiological difcuflions are 
 not immediately connecfled with our fub- 
 jedl, and although for that reafon we fhall 
 not often enter into them ; yet we can- 
 not here avoid remarking the very clear 
 proof which after this operation always oc- 
 curs, of the great dependence one part of the 
 human frame has upon another. The nerves 
 we know to be the inftruments of fenfe 
 and motion; but on being deprived of their 
 ufual fupport from the fanguiferous fyflem, 
 their influence immediately diminiflies. 
 
 Immediately after this operation, the 
 want of feeling in the parts is often very- 
 great ; and in proportion as the circulation 
 in the under part of the member becomes 
 more confiderable, the degree of feeling alfo 
 augments. If we could fuppofe the nerves 
 of the parts below to be always included 
 in the ligature with the artery, that numb- 
 3 ne{s 
 
CL^o Of Aneurifms^ Chap. IV. 
 
 nefs which fucceeds immediately to the 
 operation, might be eafily accounted for ; 
 but I have known it happen, when I was 
 certain that nothing but the artery was 
 fecured by the ligature : And befides, al- 
 though the knot upon the nerves would 
 account for the immediate lofs of fenfi- 
 bility which fucceeds to the operation, it 
 would not in any degree ferve to explain 
 the return of feeling on the circulation be- 
 ing again reftored ; for the nerve having 
 been deftroyed by the efFe<5l$ of the ligature, 
 if the want of feeling produced here origi- 
 nated entirely from that circumftance, it 
 could not be expeded to be much influen- 
 ced by the return of blood to the part. 
 
 In the mean time the patient being proi- 
 perly attended to as to regimen, by giving 
 him cordials and nourifhing diet when low 
 and reduced, and confining him to a low 
 diet if his conftitution is plethoric, the 
 limb being flill kept in an eafy relaxed 
 pofture, towards the end of the fourth 
 or fifth day, fometimes I have known it 
 much fooner, a very weak feeble pulfe is 
 
 difcovered 
 
Sed.II. OfAneurlfm, 252 
 
 difcovered in the under part of the mem- 
 ber, which becoming flronger in a gradual 
 manner, the patient in the fame proportion 
 recovers the ufe and feeling of the parts. 
 
 As fpon as there is an appearance of mat- 
 ter having formed freely about the fore, 
 which will feldom happen before the fifth 
 or fixth day, an emollient poultice Ihould 
 be applied over it for a few hours, in order 
 to foftenthe drefhngs, which may be then 
 removed. At this time, too, the ligatures 
 might be taken away ; but as their conti- 
 nuance for a day or two longer can do no 
 harm, it is better to allow them to remain 
 till the fecond or third dreflxng, when they 
 either drop off of themfelves, or may be 
 taken away with perfetfl fafety. The drcf- 
 iings, which fhould always be of the fofteft 
 materials, being renewed every fecond or 
 third day according to the quantity of 
 matter produced, the fore is in general 
 found to heal very eafily ; and although 
 the patient may for a confiderable time 
 complain of a great degree of numb- 
 nefs and want of ilrength in the whole 
 
 courfe 
 
253 of Aneurifms, .Chap. IV. 
 
 courfe of the difeafed limb, yet in moft 
 inftances a very free ufe of it is at laft ob- 
 tained. 
 
 It will be readily fuppofed, that the ter- 
 mination of this operation as we have here 
 defcribed it, is the m.oft favourable that 
 can poflibly happen. In fome inftances, 
 the fuecefs attending it is far from being 
 fo complete : Inftead of a return of circu- 
 lation, and of the feeling and ufe of the 
 parts, they remain cold and infenfible, and 
 no marks of returning Ufe are perceived. 
 From a mere want of blood, therefore, mor- 
 tification at laft commences ; and as na- 
 ture is here deprived of one of her princi- 
 pal agents for the removal or feparation of 
 gangrenous parts, I mean the efforts of the 
 fanguiferous fyftem, whenever the parts in 
 fuch circumftances begin to mortify, no- 
 thing can prevent their progrefs to the ul- 
 timate ftage of that malady. 
 
 Whenever mortification enfues, there- 
 fore, as a confequence of this operation, if the 
 patient furvives the immediate efFe(5ls of it 
 till a feparation occurs between the healthy 
 
 and 
 
Se<i^. It. Of Aneurifm\ £j3 
 
 and difeafed parts, amputation of the mem- 
 ber will then be the only refource. 
 
 That this operation when praAifed upon 
 the principal artery of the fuperior part of 
 a member, does now and then terminate 
 in this manner, no practitioner of experi- 
 ence will deny ; but its doing fo in fome 
 inftances, is not a fufficient reafon for re- 
 ceding it in every cafe. The event of every 
 capital operation we know to be very un- 
 certain ; and in this, as in every other of 
 equal importance, as we cannot in any 
 cafe fay with precifion how it is to anfwer, 
 fo we are never to put it in pratlTtice where 
 means of a lefs hazardous nature will fuc- 
 ceed: And on the contrary, whenever thefe 
 are found to fail, and the patient's life 
 comes to be in danger, it ought undoubt- 
 edly to be performed without farther heii- 
 tation. 
 
 GHAP. 
 
i^^ Of Hernia. Chap.V, 
 
 CHAP. V. 
 (y He R N IJE. 
 
 SECTION i. 
 Of Hernia in generaL 
 
 ^TpHE term Hernia might with propriety 
 be applied, to every fwelling occa- 
 fioned by the diflodgment of parts front 
 thofe boundaries within which in a (late 
 of health they are contained; but the term 
 in its general acceptation, implies, a tumor 
 produced by the protrufion of fome part or 
 parts from the cavity of the abdomen. 
 The parts in which thefe fwellings ufu- 
 ally appear, are the groin, fcrotum, labia 
 
 pudendi-, 
 
Sedl. I. Of Hernia, 
 
 ■^i 
 
 pudeadi, the upper and fore part of the 
 thigh, the umbilicus, and different points 
 between the incerftices of che abdominal 
 mufcles. 
 
 If the fituat;ion of fuch tumors be va- 
 rious, the vifcera which they contain are 
 ftill more fo; inftances having occurred of 
 the ftomach, uterus, liver, fpleen, and blad- 
 der, being found to form their contents. 
 But a part of the inteflinal canal, or a por- 
 tion of the omentum, are from experience 
 known to be the moft frequent caufe of 
 their formation. 
 
 From thefe circumftances of fituation 
 and contents, all the different appellations 
 are derived by which herniae are diftin- 
 guilhed. Thus they are termed Inguina], 
 Scrotal, Femoral, Umbilical, and Ventral; 
 from their appearing in the groin, fcro- 
 tum, thigh, navel, or belly. When the 
 tumor is confined to the groin, the hernia 
 is faid to be incomplete, and is termed Bu- 
 bonocele ; but, when the fwelling reaches; 
 down to the bottom of the fcrotum, the 
 rupture is then fuppofed to be complete, 
 I and 
 
2$G Of Hernict, Chap. V; 
 
 and the difeafe obtains the name of Scrd- 
 tal Rupture, or Ofchiocele. 
 
 When a portion of gut alone forms thd 
 tumor, it is called an Enteroceje, or Intefti- 
 nal Hernia ; when a piece of omentum 
 only has got down, it is termed Epiplocele^ 
 or Omental Hernia ; and if both inteftine 
 and omentum are down, it is called an 
 Entero-epiplocele, or Compound Rupture. 
 
 As all the abdominal vifcera are appa- 
 rently contained within the cavity of the 
 peritonaeum, and as it was thought im- 
 pofTible for that membrane to admit of 
 fuch a degree of diftention, as to furround 
 tumors containing fuch large portions of 
 the different vifcera as are at times pro- 
 truded, it was therefore commonly fup- 
 pofed, that in at leaft'the greateft number 
 of cafes of hernia, the peritoneum mufl cer- 
 tainly be burft or ruptured ; and from this 
 the term Rupture was in all fuch inftances 
 fuppofed to be applied with propriety 
 enough. The idea was farther confirmed 
 too, from its having been obferved, that in 
 cafes of fcroul hernia, the protruded vif- 
 cera 
 
Se^t^I. Of Heniice, z^j 
 
 cera were in fome inftances found in con- 
 tact with the tefticle ; a circumflance, 
 which it was fuppofed could not poffibly 
 happen, if the peritonseum had not been 
 previouily rupturedc 
 
 Since the anatomy of thefe parts, how- 
 ever, was better underdood, this circum- 
 fiance, of parts protruded from the ab^ 
 domen being on fome occafions found iii 
 contact with the tefticle, is explained in a 
 more fatisfacftory manner than on the fup- 
 pofition of a rupture of the peritonseam ; 
 an occurrence which we fuppofe will very 
 rarely happen, in any other manner than 
 from external violence: But as the nature 
 of thefe diforders cannot be properly un- 
 derftood without a previous knowledge of 
 the anatomy of the parts concerned, it will 
 be proper, before proceeding farther, to 
 defcribe fuch as here become the more 
 immediate fubjedls of operation; and thefe 
 are, a part of the abdominal mufcles ; 
 the peritonaeum ; tefticles ; and fpermatic 
 veiTels. 
 
 The fides and other fiefliy boundaries 
 Vol. I. ^ R of 
 
258 Of Hcrni<;e, Chap. V. 
 
 of the abdomen are formed by five pairs 
 of mufcles ; viz. the redli, pyramidales, 
 tranfverfales, obliqui interne, and obliqui 
 externi. 
 
 In fome fubje<fts, the pyramidales are 
 v^anting ; and as the obhqui externi are 
 in general thofe which in cafes of hernia 
 come to be mofl connecled with the dif- 
 order, we fhall here confine our defcrip- 
 tion to the anatomy of thefe only. 
 
 The obliqui externi are two thin, broad 
 mufcles : on their pofterior and upper parts 
 they are flefhy ; and tendinous on their 
 anterior and lower parts. They origi- 
 nate from the eighth, ninth, and inferior 
 ribs, by flefhy portions which intermix 
 in a ferrated manner with correfponding 
 parts of the latifTimus dorfi, ferratus ma- 
 jor amicus, peclorales major, and inter- 
 coftales : And afterwards becoming ten- 
 dinous, they form the greateft part of ail 
 ihe anterior furface of the abdomen, and 
 are infer ted into the linea alba, the fpinc 
 of the OS ilium, and into the os pubis. On 
 each fide of the under part of the abdo- 
 men 
 
St (51 . i Of Hernia, 259 
 
 men immediately above the pubes, two 
 openings are met with in thefe tendons, 
 intended for the paffage of the fpermatic 
 veiTels in men, and for the ligaments of 
 the womb in women. Thefe openings, or 
 rings as they are termed, which feem to be 
 formed merely by a feparation of the fibres 
 of the tendon from one another, are of an 
 oval figure, and have an oblique direclion 
 from the fpine of the ileum downwards ; 
 they are fomewhat wider above than be- 
 low, and are rather of a larger fize in men 
 than in women. 
 
 Although thefe rings or openings have 
 been commonly defcribed as pafling thro' 
 not only the external oblique, but the 
 tranfverfales and internal oblique mufcles 
 alfo ; yet it is now certainly known, that 
 it is in the tendinous parts of the external 
 oblique mufcle only, that any. fuch opening 
 exifts. It is of fome importance to the flu- 
 dent to be thoroughly acquainted with this 
 circumftance : for, by the accounts recei- 
 ved of it from books, one is led to fuppofe, 
 that, inflead of one diflincl pailage, there 
 R 2 are 
 
iGo Of Ucrni<x\ Chap.V. 
 
 are always three to be met with here. 
 Thefe mufcles are likewife perforated in 
 the middle by the umbilicus, which affords 
 a pafTage for the conne(fling veflels between 
 the mother and uterine foetus, and which 
 is continued through life, being filled up 
 by cellular fubftance only. 
 
 From the inferior border of the tendi- 
 i^-ous part of the external oblique mufcle, 
 a detachment of fibres is fent off, which, 
 after affording a firm covering to the in- 
 guinal glands, are loft in the fafcia lata of 
 the thigh : And the under edge of this 
 tendon being folded inwards, obtains the 
 appearance of a ligament, which flretches 
 from the fore part of the os ileum to the 
 pubes, forming a kind of arch, through 
 which pafs the great blood- veiTels of the 
 lower extremity. It is this ligamentous- 
 like portion of the external oblique mufcle, 
 which is known by the appellation of Pou- 
 pa.rt's or Fallopius's ligament. 
 
 This palTage for the blood-veflels of the 
 thigh, being larger in women than in men, 
 owing to the greater fize of the pelvis in 
 
 the 
 
Sedl. I. Of Hermk, 261 
 
 the former, by which the arch formed by 
 Poupart's Hgament is rendered both longer 
 and wider ; fo in them the crural hernia, 
 or that fpecies ot the difeafe formed by a 
 protrufion of parts through this paffage, 
 is found to occur much more frequently 
 than in men. 
 
 The internal furface of the mufcles of 
 the abdomen, together with every other 
 ,part of that cavity, is line4 with a fmooth 
 fomewhat elailic membrane^ termed Feri- 
 tonseum. This membrane, beiides lining 
 the cavity of the belly, furniflies the exter- 
 nal covering to almoll every vifcus con- 
 tained in it ; but, in fo fingular a manner 
 are thefe coverings produced, that altlio' 
 at firft fight the different vifcera appear all 
 to be contained -il^ithin the cavity of the 
 peritonsum, yet on a minute examination 
 they are in reality found to lie behind it. 
 
 The periLonsum, after having complete- ~~ 
 iy lined the cavity of the abdomen, is con-" 
 tinned or refle(fled over all the vifcera, fo 
 as to give an external covering to each. 
 After furrounding one vif:us, it flretcher, 
 R 3 along 
 
262 Of Hcrm<s, Chap. V. 
 
 along to the mofl contiguous, forming in 
 its courfe the fupporting membranous li- 
 gament of the liver and other vifcera; and 
 affording in its duplicature a kind of fup- 
 port or connedlion to the varioils blood* 
 veflels, as they flretch along to their de- 
 flined fituations in the inteftinal canal and 
 other organs. 
 
 Behind the peritonaeum lies a quantity 
 of loofe cellular fabftance, by authors 
 commonly termed its Appendix. In fome * 
 , parts this fiibftance is filled with fat ; and 
 3n others it is empty, and can eafily be 
 filled with air. 
 
 The tefles in the foetus are, till near the 
 period of delivery, lodged in the cavity of 
 the abdomen, in the fame manner with 
 the reft of the abdomiilal vifcera. Tliey 
 are fituatcd immediately below the kid- 
 neys, on the fore part of the pfox mufcles, 
 near to the upper end and l)y the fide of 
 the re(51um, where their external covering 
 adheres by its poflerior furface to thofe 
 parts of the peritonaeum on which they reft, 
 ^vhile all their anterior and lateral furfaces 
 
 lie 
 
Seel. I. Of Hernia, 263 
 
 lie loofe in the abdominal cavity in contadl 
 with the other vifcera. Even in this Situa- 
 tion, hovsrever, a connecflion takes place be- 
 tween the teftes and fcrotum. This is form- 
 ed bymeans of a fubftance which runs down 
 from the under end of the teftis to the fcro- 
 tum, forming a kind of pyramidal fhaped 
 ligament; its large bulbous head being 
 fixed to the lower end of the teftis and epi- 
 didymis; and its under extremity, after 
 having pafTed through the ring in the exter- 
 nal oblique mufcle, being loft in the cellular 
 ,membrane of the fcrotum. This ligament 
 is evidently vafcular and fibrous, and feems 
 in part to be compofed of the cremafter 
 mufcle turned inwards*'. 
 
 All that portion of the ligament con- 
 tained within the ^arietes of the abdomen 
 pafFes behind the peritoneum, and receives 
 a covering from it in the fame manner with 
 the teftes and other vifcera; and the peri- 
 tonseum even gives a coat to a portion of 
 R4 the 
 
 See a very accurate account of the Anatomy of 
 :hefe parts by Mr J. Hunter, in Dr Hunter's Medical 
 Commentaries. 
 
264 Of Hernia, Chap.V, 
 
 the ligament after it has got into the groin, 
 by palling down along with it from the ab- 
 domen into the upper part of the inguen. 
 
 At this place, viz. at the annular open- 
 ing of the external oblique mufcle, the 
 peritonxum is very loofe; and when the 
 ligament and fcrotum are drawn down- 
 vrards, an aperture is obferved from the 
 cavity of the abdomen all around the fore 
 part of the ligament, which feems ready to 
 receive the teftis ; and this aperture gra- 
 dually becomes larger as the teftis defcends 
 behind the peritonncum it its way to the 
 fcrotum. While the tefticle is ready to 
 defcend, it does^ not fall down, as has been 
 commonly imagined, along the fore part of 
 the peritoneum, between it and the other 
 vifcera; but this ligament we have now 
 defcribed as lying behind the peritonoeum, 
 and which is connected with the teftis 
 at its under and pofterior parts, by di- 
 re(3:ing or pulling it down as ic were from 
 behind, brings it in this manner along the 
 pfoas mufcle between it and the perito- 
 n32um J and that part of this membrane 
 
 to 
 
Sed. I. Of Hernia, q.6^ 
 
 to which we have fhown that the tefticle 
 adheres, being necefTarily drawn along 
 with it, a kind of pouch or bag, fome- 
 what refembling the finger of a glove, is 
 thus formed by this elongation of the pe^ 
 ritonseum ; the under extremity of which 
 flil continues to furround the teftis as it 
 goes along, in the fame manner as it did 
 when that vifcus relied upon the pfoas 
 mufcle; and the entrance from the abdo- 
 men to the cavity of this procefs, is exadly 
 at that point where the teftis was origi- 
 nally fituated ; for it is there that this pro- 
 cefs commences when the teftis begins"to 
 defcend. 
 
 The peritonseum being in a foetus re- 
 markably lax and dilatable at this part, 
 and being connedled pofteriorly, as we have 
 feen, with a quantity of very loofe cellular 
 fubftance, its elongation produced by the 
 defcent of the tefticle is in this manner 
 provided for by nature, and of courfe is 
 eafily admitted of. 
 
 It muft not, however, be fuppofed, that 
 the teftis and peritonceum in coming down 
 
 fall 
 
a66 Oflhrnicd, Chap. V. 
 
 fall loofely and without conne6lion ; for, 
 as they Hide down very gradually, they 
 ftill continue to adhere to the parts lying 
 behind them as they did when in the ab- 
 domen. 
 
 The precife time at which the teftis paiTes 
 down from its original lituation in the ab- 
 domen, cannot be exadtly determined; but 
 in general, this change takes place about the 
 eighth month. About this period, the. teftis 
 furrounded with the peritoneal procefs, 
 moves downwards till its under extremity 
 comes into contact with the moft inferior 
 point of the abdominal parietes; and by 
 this time the paflage through the tendon of 
 the external oblique mufcle is found a 
 good deal enlarged, by the ligament of the 
 teftis having funk downwards fo as to pro- 
 duce a confiderable dilatation of it. 
 
 After the teftis has paiTed the tendon of 
 the mufcle, it commonly remains for fome 
 time by the fide of the penis, and by de- 
 grees only defcends to the bottom of the 
 fcrotum; and even when it has got entirely 
 into the fcrot um, its hgament is ftill con- 
 2 r.ecled 
 
Seel: I. Of Hernia. 26 j 
 
 nedled with it, and lies immediately under 
 it, but is fhortened and comprefTed. 
 
 The procefs of the peritonaeum, which 
 we have Ihown to defcend with the tefticle, 
 continues to cover it when it has reached 
 the fcrotum : and it is this loofe covering 
 or bag which is afterwards converted into 
 what Anatomifts term the Tunica Vaginalis 
 "Tejiis; and from the defcription we have 
 given of it, it is evident, that the cavity of 
 this bag muft at firft communicate with 
 the great peritoneal cavity of the abdomen. 
 This it accordingly does, as a probe may 
 be pafTed readily and eafily along this pro- 
 cefs or bag, from the belly down to the 
 bottom of the fcrotum ; and if it be laid 
 open through its whole length on the fore 
 part, it will be plainly feen to be a conti- 
 nuation of the peritonaeum ; the teftis and 
 epididymis will be found at the lower part 
 of it without their loofe coat the tunica 
 vaginalis; and as the fpermatic veflels and 
 vas deferens, while the teilicle remained in 
 the abdomen, entered the body of it be- 
 hind, and between the reflecled lamina of 
 
 the 
 
26^ O/HernU, Chap. V. 
 
 the peritoneum, fo here when in the fcro- 
 tum they will be found covered by the pof- 
 terior part of the bag, in their whole courfe 
 from the commencement of that procefs 
 down the groin to the tefticle. 
 
 This pafTage from the cavity of the ab- 
 domen to the fcrotum is in general very 
 foon cut off, by a firm adhedon being pro- 
 duced between the fides of the peritoneal 
 procefs at its upper extremity where it de- 
 fcends from the abdomen. What the caufe 
 of this adhefion may be, is uncertain ; per- 
 haps it may proceed from fome flight de- 
 gree of inflammation being excited upon 
 the contiguous parts by the forcible paffage 
 of the teftis; but whatever the caufe may 
 be, the fad: is, that at the time of birth 
 this paffage in general is completely obli- 
 terated*. 
 
 It 
 
 * The defcent of the tefles from the abdomen is a 
 phenomenon very difficult to account for, and its im- 
 mediate caufe may probably always remain a myflery; 
 but their being in almofl every inflance found in the 
 fcrotum before birth, is a clear proof of their not be- 
 ing forced down by the effetSls of refpiration, as has 
 been commonly fuppofed. 
 X 
 
Sea J. OfHernU. 26^ 
 
 It is in the neck only, however, or fu- 
 perior part of this procefs, that fuch an ad- 
 hefion takes place ; as the lower extremity 
 of the fac remains open and loofe through 
 life, and forms, as we have already faid, 
 the tunica vaginalis teftes : the common 
 feat of a hydrocele. 
 
 If the faiaileft attention be given to this 
 defcription, it rauft appear evident, that if 
 immediately upon the tefticle defcending 
 from the abdomen, and before the palTage 
 is fufEciently contradled, any portion of 
 the alimentary canal or omentum fhoul^d 
 likewife fall into the opening, fuch parts 
 mud for certain lodge in the fame bag 
 or covering with the teftis itfelf ; and 
 that as long as they remain there, they 
 muft efFeflually prevent the ufual oblite- 
 ration of the pafTage from being accom- 
 plifhed. 
 
 It is this occurrence, of a portion of 
 fome of the abdominal vifcera getting into 
 the tunica vaginalis teftes, which forms 
 that fpecies of hernia to which new-born 
 infants are liable, termed by Haller the 
 
 Hernia 
 
270 Of Hernia. Chap. V. 
 
 Hernia Congenita. The teflicle and pro- 
 truded inteftine being here in conta6l with 
 one another, the tunica vaginaHs teftis 
 forms the hernial fac. 
 
 If the gut, or other parts which have 
 fallen down, be again pufhed into the ab- 
 domen, and are retained there by proper 
 bandages or any other means, in that cafe 
 the pafTage is foon clofed up, and no re- 
 turn of the diforder is obferved. But this 
 being negledled, and the gut being allowed 
 to remain long down, the parts forming 
 the paflage feem thereby in a great mea- 
 fure to lofe that power of adhefion which 
 naturally they are known to poffefs ; in- 
 flances of fuch cafes having occurred where 
 no art has been able to produce this 
 wifhed-for obliteration of the opening. 
 
 The hernia congenita is ufually pro- 
 duced in the manner now defcribed ; it is 
 probable, however, that the fame diforder 
 may, and frequently does, occur, from this 
 pafTage between the abdomen and teflicle, 
 after having been once clofed, being again 
 rendered pervious, in confequence of the 
 
 parts 
 
Sea.t Of Hernia.. 271 
 
 parts being over flrecched by thofe vio- 
 lent fits of coughing, crying, and other 
 eonvulfive afFeclions to which children 
 foon after birth are , now and then li- 
 able. The inteflinal canal and other vif- 
 cera, being on fuch occafions pufhed with 
 violence againfl all the containing parts, 
 thefe will moft eafily give way where the 
 leaft degree of firmnefs occurs ; and this 
 we may readily fuppofe will moft probably 
 happen in fuch parts as have been moft 
 recently united. In this manner it is pro- 
 bable .that the greateft proportion of thofe 
 cafes of hernia are produced which occur 
 in the early months of infancy ; and I am 
 even inclined to think, that on fome occa- 
 fions in more advanced periods of life, the 
 fame fpecies of hernia may like wife occur 
 from the fame caufe. 
 
 It is evident, then, in what manner the 
 hernia congenita is produced ; we fhall 
 now inquire into the caufes which tend to 
 the production of hernia in its more ufual 
 form. ' ' ' 
 
 L The containing parts of the abdomen , 
 
 we 
 
272 Of Hern w Chap . Va 
 
 we know to be elaftic and compreflible ; 
 whatever, therefore, tends to produce a di- 
 niinut.ion of capacity in the cavity of the 
 abdomen, muft occafion a proportional 
 degree of rilli, of feme of the contained 
 parts being puflied from their natural fitu- 
 ations. Violent coughing, crying, laugh- 
 ter, or great bodily exertion, are attended 
 with more or lefs contradion of the ab- 
 dominal mufcles, and particularly of the 
 diaphragm ; and as the contradion of 
 thefe mufcles, muft always diminifh the 
 abdominal cavity, thefe caufes therefore 
 are frequently found to be produdive of 
 hernia. 
 
 II. Falls, in confequence of the derange- 
 ment they produce in the abdominal vif- 
 cera, from the fudden and violent fliock 
 with whic'h they are often attended, are 
 not unfrequently the immediate caufes of 
 hernia. 
 
 III. Perfons of a preternatural laxity of 
 frame, are very liable to hernia. The 
 containing parts of the abdomen, from the 
 want of a fufficient tone and firmnefs, are 
 
 . 1 iinable 
 
Ssdl. L Of lie mice 3 273 
 
 imable in fucli people to refift on all oc- 
 cafions the weight of the diiFerent vifcera ; 
 and they are therefore more particularly 
 expofed to diforders of this kind on the 
 flightefl application of any of the caufes 
 already mentioned. 
 
 IV. Sprains aire apt to induce a laxity 
 of the part injured; and have therefore a 
 limilar influence in inducing hernial, with 
 general laxity. 
 
 V, It has bee;i obferved, that the peo- 
 ple of thofe countries where oil is much 
 ufed as an article of diet, are particularly 
 liable to hernias. 
 
 In whatever parts the parietes of the ab-^ 
 domen happen to be weakefl, thefe various 
 caufes will moft readily operate in produ- 
 cing herniae ; and accordingly we find,! 
 that defcencs of the bowels ufuallv occur 
 only in fueh parts. 
 
 The parts which from anatomy we would 
 a priori fufped: to be moift liable to fuch 
 protrufions, are, the openings already de- 
 fcribed in the external oblique mufcles ; 
 the arch formed by Pou part's ligament for 
 
 Vol. I. S the 
 
2 74 Of Henna, Chap. V. 
 
 the pafTage of the great blood- vefTels of the 
 thigh ; and the umbilicUvS, where the fame 
 degree of firmnefs does not take place as is 
 met with in the reft of the tendinous ex- 
 panlion of the abdominal mufcles. 
 
 Thefe, as we have already faid, are the 
 ufual feats of hernia ; but it fometimes 
 happens that parts of the vifcera are pro- 
 truded between the interftices of the diffe- 
 rent mufcles of the abdomen: Thefe, how- 
 ever, are not frequent occurrences. 
 
 In whichever of thefe fituations a pro- 
 trufion of any portion of the inteftines oc- 
 curs, except in the cafe of the hernia con- 
 genita, as all the vifcera are contained in 
 the manner already defcribed within the 
 peritoneum, a portion of that membrane, 
 it is evident, muft be carried down to- 
 gether with the parts protruded ; and in 
 'every fuch inflance, it is this portion of 
 the peritonsEum which goes down along 
 with the gut that is termed the Hernial 
 Sac. The fize of this fac is various in dif- 
 ferent fubjeds, and in different flages of 
 the fame diforder. 
 
 On 
 
feed, h Of Hemw^, ^^^ 
 
 On the firft appearance of the difeafej; 
 the fac is commonly of no very conlider-- 
 able iize, as fuch fwellings feldom acquire 
 any great bulk at once : But by repeated 
 defcents of the bowels, the fac comes to 
 be pufhed lower and lower, till in fome 
 inftances its bulk becomes very confider- 
 able indeed ; and when in this advanced 
 period of the diforder the fac happens to 
 be laid open, it is found to contain either 
 large quantities of omentum or inteRinej 
 and frequently large portions of each. 
 
 As the peritonaeum has this property in 
 common with many other parts of the 
 body, of thickening according to the de- 
 gree of any gradual extenfion applied to it, 
 fo in many inftances the thicknefs and 
 firmnefs of the hernial fac are often really 
 aftonifhing. 
 
 Although every inftance of a bowel pro- 
 truded from its natural fituation is to be 
 confidered as a derangement, and as fuch 
 demands our attention, yet daily inftances 
 occur, both of recent herniae, and of chofe 
 of longer fta;nding,in which no bad fymp- 
 S 2 toms 
 
ijG Of Herni(S. CKap. V. 
 
 toms are produced by fuch protrufions 
 of the vifcera. Thus it is well known, 
 that hernial fwelllngs of every kind very 
 frequently happen, without the patient 
 fuffcring in any other manner, than from 
 the inconvenience arifing from the bulk 
 of the tumors. But in general this is 
 otherwife ; troublefome fymptoms moft 
 frequently occur ; and at all events, when 
 the reduction of a hernia can be ac- 
 complifhed with any kind of propriety, it 
 ought always to be efFecled as quickly as 
 poflible. 
 
 All the bad fymptoms which are found 
 to occur in hernise, proceed, as may be 
 readily fuppofed, either from obftrudion 
 to the paiTage of the feces when the inte- 
 ftinal canal forms the tumor, or from 
 a floppage of circulation occafioned by 
 {lri(flure on the prolapfed parts ; fo that 
 the attending fymptoms, it is evident, 
 will be always more or lefs hazardous, ac- 
 cording to the nature of the parts fo pro- 
 truded. 
 
 Thus, when a portion of the omentum 
 
 alone 
 
Sed. L Of Hernia, 277 
 
 alone forms the fubftance of hernial fwel- 
 lings, as that organ does not appear to be 
 fo immediately neceffary to life as many of 
 the other vifcera, fuch tumors accordingly 
 are not fo frequently produdlive of bad 
 confequences, at lead they are feldom in 
 any degree fo hazardous, as when a part 
 of the alimentary canal is either protruded 
 by itfelf, or along with omentum. 
 
 Although this, however, is in general the 
 cafe; yet it does fometimes happen, that 
 even an omental rupture is producflive of 
 no fmall degree of danger. When a ftric- 
 ture fo complete upon it occurs, as to oc- 
 cafion a floppage of circulation in the pro- 
 truded part, mortification with all its bad 
 confequences muft be the certain event: 
 And befides, the connedlion between the o- 
 mentum, {lomach,and other vifcera, is fuch, 
 that a fudden defcent of any confiderable 
 portion of the former fometimes brings on 
 vomiting, hickup, and other troublefome 
 fymptoms: And laftiy, although a rupture 
 containing omentum, only, might not of 
 itfelf produce any thing bad j yet as the 
 S 3 ' paffage 
 
2^8 Of Hernia, Chap.V. 
 
 paffage through which the omentum has 
 lllpped, mull of necefiicy continue open as 
 long as that vilcus remains protruded, and 
 as that circumftance alone muft as long as 
 it continues render it more eafy for a por- 
 tion of gut Hkewife to get down, this of 
 itfelf is a fufEcient reafon for beflowing 
 even upon this fpecies of hernia our fe- 
 rious attention. 
 
 But whatever the contents of fuch fwel- 
 lings may be, as their remaining in fome 
 inftances for a confiderable length of time 
 without being productive of any bad fymp- 
 toms, muft proceed entirely from the cir- 
 culation continuing to go freely on, not- 
 wuthflanding the derangement of parts ; 
 fo, whenever a ftridlure occurs upon the 
 protruded vifcera, fuiEcient to produce ei- 
 ther a ftoppage of the circulation, or of the 
 fascal contents of the alimentary canal when 
 a portion of gut forms the difeafe, the fol- 
 lowing in general are the fymptoms which 
 accrue. 
 
 An elallic colourlefs fwelling is obferved 
 at the part ^iffeded j a flight pain is felt, 
 
 not 
 
Se6l. L Of Hernite, . 279 
 
 not only in the fwelling itfelf, but, if part 
 of the alimentary canal is down, an univer- 
 fal uneafinefs is perceived over the whole 
 abdomen; and this pain is always ren- 
 dered worfe by coughing, fneezing, or any 
 violent exertion. The patient complains 
 of naufea ; frequent retching ; can get no 
 difcharge by flool ; becomes hot and reft- 
 lefs ; and the pulfe is commonly found 
 quick and hard. 
 
 If the fwelling is entirely formed by a 
 portion of gut, and if no feces are con- 
 tained in it, it has a fmooth, equal furface; 
 and is eafily compreffible, but inflantly 
 returns to its former fize on the prefTure 
 being removed. But, in gut ruptures of 
 long (landing, where hard feces have col- 
 ledled in the protruded bowels, coniider-' 
 able inequalities are detedled. 
 
 When again the tumor is corapofed 
 both of gut and omentum, its appearance 
 is always unequal, it feels foft and fome- 
 what like dough, and of courfe is not fo 
 elaflic as when part of the inteftinal tube 
 pnly is down ; for although like the other 
 S 4 ' it 
 
iBo Of Hernia, Chap. V. 
 
 jt is comprefTible, it does r)ot fo readily re- 
 gain its former dimenfions on the prefTure 
 being ta^en off. 
 
 It has been a received opinion, that in 
 cafes of ftrangulated hernia, the fymptoms 
 fhould be lefs violent when the inteftine is 
 accompanied by a portion of omentum, 
 than when gut alone is down. Little or no 
 difference, however, is produced by thig 
 circumilance ; for when a gut becomes ob- 
 {lru6ledand inflamed, the fymptoms there- 
 by induced are nearly the fame whether 
 the omentum be down with it or not. 
 
 It will be readily fuppofed, however, 
 that the fymptoms we have defcribed ne- 
 "wer can happen from the prefence of o- 
 mentum only : For although ftridlure pro- 
 duced on a portion of omentum, even 
 when no part of the inteft inal tube is down, 
 does now and then occafion a good deal of 
 diftrefs, fuch as pain in the part, ficknefs, 
 vomiting, and twitching pains through 
 the whole belly ; yet no cbflruc^lipn of 
 the gut ever occurs from this, and of 
 coiirfe none of the fymptoms ever prove 
 
Sea. I. OfHernu. 281 
 
 fo alarming as when any part of the gut 
 is concerned. 
 
 If thefe fymptoms we have defcribed 
 as being produced by a ftrangulated gut, 
 are not now obviated by a removal of the 
 {iri(flure which produced them, the nau- 
 fea and retching terminate in frequent 
 vomitings, firfl: of a bilious, and after- 
 wards of a more fetid matter ; the belly 
 becomes tenfe ; the pain turns more vio- 
 lent; a diftrelTmg convulfiye hickup 
 comes on ; and the fever, which before 
 was not apparently of much confequence, 
 now becomes very formidable, and a total 
 want of reft with a very difagreeable ftate 
 of anxiety continues through the whole 
 courfe of the complaint. 
 
 Thefe fymptoms having gone on with 
 violence for fome time, the patient is at 
 laft for the moft part fuddenly relieved 
 from all manner of pain, when he flatters 
 himfelf every rifle is for certain over. 
 But infl:ead of that, the pulfe, from ha- 
 ying been hard and frequent, becomes 
 ^nguid and interrupted; cold fw^ats break 
 
 out 
 
282 . Of Hermes, Chap. V, 
 
 out over the whole body, but efpecially on 
 the extremities ; the eyes acquire a kind of 
 languor; thetenfenefs of the abdomei-v fub- 
 ildes,, and the fwelUng of the part affecfled 
 difappears; the teguments covering the 
 parts, which before were either of a natu- 
 ral appearance, or had fomewhat of a red- 
 diili inilaiTied caft, now acquire a livid hue, 
 and a windy crepitous feel is diftinguifli- 
 able all over the fwelling. 
 
 If the protruded parts have not of them- 
 felves gone entirely up, their return is now 
 in general eafily effedled by a fmall degree 
 of preiTure, and the patient then difcharges 
 freely by (tool ; but the cold fweats in- 
 creafing, the hickup turns more violent 
 and death itfelf is at lad ulhered in by its 
 ufual fore-runners, fubfultus tendinum 
 and other convulfive twitchings. 
 
 Thefe are the ordinary fymptoms of what 
 is termed a (Irangulated or incarcerated gut 
 hernia ; that is, when the parts protruded 
 become fo affeded by ftricflure, as to pro- 
 duce pain ; and do not either return to their 
 natural fituations on the patient getting 
 
 into 
 
^ea.I. of Hernia, 283 
 
 mto a horizontal poflure, or cannot even 
 be immediately replaced by the hands of 
 a praditioner. 
 
 In whatever fituation a flrangulated 
 hernia occurs, the only rational method of 
 cure, it is evident, mud confifl in the re^ 
 moval of that ftridure which prevents the 
 return of the protruded parts. It is that 
 which ought to be conlidered as the caufe 
 of all the mifchief ; and unlefs it be re- 
 moved, nothing efFedlual can be done for 
 the relief of the patient. 
 
 Various methods have been attempted 
 by pradlitioners for the removal of (Iriq- 
 ture in thefe diforders ; all of them, how- 
 ever, may be comprehended under two ge- 
 neral heads. 
 
 I. Such as effe6l a redudion of the pro- 
 truded parts, without the interpolition or 
 incifion or any chirurgical operation pro- 
 perly fo called 5 and, 
 
 II. A divifion of the parts producing the 
 ftridture, fo as to admit of a replacement 
 of the deranged vifcera, conftituting what 
 i^ termed the Operation for the Hernia. 
 
 The 
 
284 of Hernia, Chap. V, 
 
 The remedies to be employed for accom- 
 pliihing the firfl of thefe, are, a proper po- 
 flure of the patient, with the manual ailift- 
 ance of a pracflitioner ; blood-letting; fti- 
 jnulating glyfters ; opiates ; the warm bath ; 
 and proper applications to the tumor itfelf. 
 
 As foon as the affiflance of a praditioner 
 is defired for the removal of fympioms in 
 cafes of hernia, the firft clrcumftance re- 
 quiring his attention, is, the placing his 
 patient in fuch a poflure as will moft pro- 
 bably favour the return of the protruded 
 parts. ThuSi when the tumor is in the 
 groin, or in the fore- part of the thigh, the 
 patient ought to be fo placed, as to raife his 
 thighs and legs confiderably higher than 
 his head and trunk; that is, he fhould be 
 placed almoU perpendicularly upon his 
 head. 
 
 This pofidon caufes aimed the whole 
 quantity of inteftines to hang or fwing 
 by the protruded parts, which frequently 
 proves a means of efFedling their redudlion. 
 Placing the patient's feet over the fhoulders 
 of another perfon, while at the fame time 
 I his 
 
Sea. I. OfUerni^. 285 
 
 his body is allowed to hang downwards, 
 and cauling him in this pofture to be a 
 good deal jolted about, has on Tome occa- 
 fions been known to anfwer when e very- 
 other means has been tried in vain. 
 
 For the fame reafon that in the inguinal 
 and femoral hernia the pofition now men- 
 tioned is more advifable than any other, 
 the ufual ere(fl pofture of the boriy becomes 
 moft proper in cafes of exomphalus or um- 
 bilical rupture ; and again, a horizontal 
 pofture is moft likely to prove ferviceable 
 in cafes of ventral hernia. 
 
 While the patient thus remains in the 
 moft fuitable pofture according to the feat 
 of the diforder, the furgeon ftiould at the 
 fame time endeavour to affift the return 
 of the gut or other parts, by means of 
 gentle prefTure with his hands and fin- 
 gers. In the inguinal or fcrotal hernia, 
 this prefTure fhould be made obliquely 
 upwards towards the os ileum, fo as to 
 eorrefpond as nearly as pofhble with the 
 opening in the external oblique mufcle. 
 In the femoral hernia, the prefTure ought to 
 
 be 
 
2o6 C/Hcrmce. Chap. V/ 
 
 be made diredly upwards ; in the unxbillcal 
 hernia, downwards and backwards ; and 
 in the ventral hernia, direflly backwards. 
 When tumors of this nature are of any 
 confiderable fize, prefTure. as we have here 
 recommended, is moft conveniently made, 
 by grafping the fwelling with one hand 
 from the bottom upwards, while with the 
 fingers of the other hand we endeavour to 
 pufli forward the contents at the fuperior 
 part of the tumor. Some furgeons, in 
 pufhing forward the inteftine, employ the 
 fingers of both hands at the upper part of 
 the tumor ; but the fame purpofe is an- 
 fwered equally well with the index and 
 middle finger of one hand, while the other 
 hand is employed to great advantage in 
 prefllng the under part of the tumor up- 
 wards fo as to co-operate in this manner in 
 the reduflion of the parts. It is this ope- 
 ration which by authors is termed the /axis. 
 No defcription, however, can convey an 
 adequate idea of the manner of performing 
 it properly: for, like many other circum- 
 ftances in the art of furgery, the knowledge 
 
 of 
 
Sea.L Of Hernia, 287 
 
 of it can only be acquired by repeated ex- 
 perience and attentive obfervation: But this 
 muft always be had in view, that any pref- 
 fure that is applied, mufl be of the moft 
 gentle kind ; for every thing of this nature 
 that creates much pain, is very prejudicial, 
 and ought by all means to be avoided. 
 
 If a very moderate degree of prcfTure ap- 
 plied in the manner defcribed, does not ef- 
 fect a redu(5lion of the tumor, other means 
 mufl be immediately employed. Blood- 
 letting is here a principal remedy. In no 
 diforder is it either more indicated from 
 appearances, or affords more relief in rea- 
 lity. The quantity to be taken away ought 
 in a great meafure to be determined by the 
 ftrength of the patient : But if in any cafe 
 we can with propriety venture upon ab- 
 flradling large quantities of blood from 
 weak people, it is here ; and it is often 
 aftonifhing to what length this evacuation 
 is carried in cafes of hernia without being 
 producftive of any prejudice to the fyftem. 
 A (late of deliquium being known to pro- 
 duce a more effectual relaxation of the va- 
 rious 
 
28S Of Hernia, Chap. V. 
 
 rious mufcular pares of the body, than can 
 be obtained by any other means, it has 
 fometimes been advifed, in cafes of hernia, 
 to take off fuch large quantities of blood, 
 and in fuch a fudden manner, as to pro- 
 duce fainting ; and the praiflice has now 
 and then been attended with advantage. 
 
 As an obftinate coftivenefs is commonly 
 one of the moil alarming fymptoms of 
 hernia, it has been a common pradtice to 
 prefcribe not only a variety of flimula- 
 ting purgatives by the mouth, but injec- 
 tions compofed of the mod acrid materials. 
 From all the experience, hov^rever, which I 
 have had in diforders of this nature, lam 
 convinced that purgatives are very feldom 
 produflive of much good ; and when they 
 do not prove ufeful, they almoft unlverfally 
 do mifchief, by increafing not only the (ick- 
 nefs at ftomach which always prevails here^ 
 but even by adding to the pain and ten- 
 fion of the tumor. I am clear, therefore, 
 that remedies of this kind fhould not be 
 puftied fo far as they commonly are ; and 
 when they are applied, inftead of purga- 
 tives 
 
L'LMfeVT 
 
 './/3e/AAyf//f ! 
 
SeA. L Of Herm<£, 289 
 
 tives by the mouth, which always prove 
 very naufeating, and in this (late are ufu- 
 ally reje^ed by the ftomach, I would re- 
 commend tobacco-fmoke thrown up ia 
 theform of inje(5lions, as preferable to every 
 other remedy. A variety of machines have 
 been contrived for injecfling fmoke by the 
 anus ; but none of them 1 have met with 
 anfwer the purpofe either fo eafily or fo 
 efFedually as the inftruments reprefented 
 in Plates VL and VII. They are eafily pro- 
 cured ; and by means of either of them, 
 fmoke may be inje(5led with any necelTary 
 degree of force. 
 
 I would not have it fuppofed, however^ 
 that 1 recommend tobacco-fmoke ufed in 
 this manner as an infallible purgative, as 
 many have done. For the contrary is 
 certainly the cafe ; I have known it ufed 
 in a great number of cafes both of hernia 
 and ileus, and feldom with any advan- 
 tage. I only advife it as the mod effec- 
 tual remedy of this kind with which I am 
 acquainted; and I know that the method 
 here recommended of injeding it, is the 
 
 Vol, I. , T molt 
 
2go of Hcrnice^ Chap. V. 
 
 mod efFe6lual hitherto invented. Ic has 
 been objecfled to thefe inftruments we have 
 delineated, that we cannot when they are 
 employed afcertain the quantity of fmoke 
 injecfled. But this is a nicety of little im- 
 portance ; as the rule in all fuch cafes 
 Ihould be, to continue to throw up the 
 fmoke, either till it has produced the wifli- 
 ed for effedl, till a eoniiderable degree of 
 ficknefs is induced, or till the abdomen is 
 found to be fomewhat diftended by it, as 
 in fome patients a third or even a half more 
 may be necefTary for this purpofe than is 
 found to anfwer in others. 
 
 But although this remedy does not fre- 
 quently anfwer as a purgative, it often, 
 both in cafes of hernia and ileus, proves 
 a very effecflual anodyne. And as we are 
 frequently in fuch cafes deprived of the 
 advantage of opium, by its being rejeded 
 by the (lomach, in fuch inftances, when 
 the pain is very fevere, it may be always 
 employed as one of the bed means of pro- 
 curing eafe. 
 
 With the fame view as the remedy laft 
 
 men- 
 
nate YH 
 
 '_y^.;^ 
 
 ^W/Jr//f/ru//t! 
 
Se6l. I. Of Ihrntid. 29! 
 
 mentioned, acrid fuppofitories, compofed of 
 foap, aloes, and other ftimulating materials^ 
 have been reccinmended; and when reme- 
 dies of this clafs are to be ufed, thefe may- 
 be confidered as a neceiTary addition to the 
 other purgatives; but no great dependence 
 ought ever to be placed upon them. 
 
 I knoWj we are told that in fome cafes 
 of hernia, the ufe of drafbic purgatives has 
 been of advantage; but I have fo frequent- 
 ly known them do harm, by increafing 
 the naufea, pain, and inflammation of the 
 flrangulated gut, that I am under no difE- 
 culty in faying that they ought feldom, if 
 ever, to be ufed in any cafe of hernia, 
 
 Opiates are here often of fervice, not 
 only by relieving pain, but as tending to 
 relax thofe parts which, by being preter- 
 naturally conflridled^ we conlider as the 
 principal caufe of the diforder. We have 
 already obferved, however, that the con- 
 ftant retching which occurs in mod cafes 
 of hernia, prevents the exhibition of opiates 
 by the mouth; but in fuch inftances they 
 may be applied with fome advantage in 
 T 2 ths 
 
292 Of Hernia, Chap. IV. 
 
 the form of injedlion, and their ufe may be 
 alternated with that of tobacco- fmoke as 
 we have above recommended. 
 
 Warm bathing is another remedy from 
 which much advantage has been received 
 in diforders of this nature. It is not the 
 local application of heat, however, in the 
 form of poultices and fomentations, &c. 
 we mean to recommend, but the univerfal 
 warm bath, in which the whole body is 
 immerfed, and which we know to be pof- 
 felled of very relaxing powers. 
 
 The latter, viz. the general warm bath, 
 by tending to relax the conO:ri(5lion on the 
 protruded inteftines, has frequently had a 
 confiderable influence in promoting their 
 replacement; but the former, viz, poultices 
 and other means of applying local heat ta 
 the fwelled parts, although commonly em- 
 ployed, are undoubtedly very prejudicial. 
 On the conftridled tendon they can have no 
 influence, for it always lies fo deep as to be 
 out of the reach of every local application 
 of this nature : And as the heat conveyed 
 by fuch remedies, mnft for certain tend to 
 
 rarefy 
 
Sed. L Of Hern'ne, 29^ 
 
 rarefy the contents of fuch fwellings, by 
 their thus producing an increafe of fize in 
 the tumors to which they are applied, in- 
 ftead of anfwering any good purpofe, on 
 this principle it is evident they mud do 
 harm ; and accordingly, whoever will at- 
 tentively obferve their effects, will find this 
 to be the cafe. When the external tegu- 
 ments are much inflamed and painful, by 
 their emollient properties they now and 
 then aifbrd fome relief; but the eafefo ob- 
 tained is only momentary, as the pain com- 
 monly foon becomes more violent than 
 before they were employed. 
 
 AVhoever attentively confiders the nature 
 of thefe difordersj'and the means general- 
 ly found mod effedlual in relieving them, 
 will probably coincide with us, in impu- 
 ting the bad fymptoms which occur in 
 cafes of hernia, to a (Iridlure induced up- 
 on the protruded parts. By many, how- 
 ever, a contrary opinion has been incul- 
 cated : and the principle caufe of the va- 
 rious fymptoms which occur here, has 
 been fuppofed to be, inflammation, or fome 
 T 3 fpafmodic 
 
$94 Of He mice, Chap.V* 
 
 fpafmodic afFection of the protruded parts, 
 independent of any ftriclure of the parts 
 through which thefe have pafTed. 
 
 That inflammation of the prolapfed 
 bowels, whatever may originally have pro- 
 duced it, will in general terminate in all 
 the fymptoms of flrangulated hernia, no 
 perfon will deny; but that ftridureof the 
 furrounding tendons is by much the mod 
 frequent caufe of them, we think is fo very- 
 obvious, as to render it quite unneceffary 
 here to adduce any arguments in fupport of 
 the opinion : This, however, we mud re- 
 mark, that even on the fuppolition of the 
 origin of all the mifchief lying in the pro- 
 truded parts themfelves, and not in any 
 ftriclure of thofe through which they pafs, 
 Hill the impropriety of warm applications 
 muft he equally obvious, as by the rarefac- 
 tion they induce, they muft always tend 
 to produce an additional degree of fwelling 
 in the contents of the hernial tumor. 
 
 Independent, however, of any theoretical 
 reafoning, I can with certainty aver, that in 
 pr?;dice, much nciore advantage is obtained 
 
Scdl • I. Of Hernia. 2 95 
 
 in diforders of this kind, from cooling ap* 
 plications, than from thofe of an oppofite 
 jiatm'e. In different inllances I have ven- 
 tured on the application of ice and fnow, 
 fometimes with evident advantage, and I 
 never faw them do harm *. But in gene- 
 ral, the remedies I depend moft on here, 
 are, cold faturnine folutions, and cloths 
 kept conftantly moifl with , a mixture of 
 cold water and vinegar. 
 
 By a proper application of one or other 
 of the remedies now mentioned, or by a due 
 combination of all of them, many cafes of 
 hernia are relieved without any farther 
 affiftance : But it frequently happens, not- 
 withftanding every endeavour, that the 
 protruded parts cannot be returned; the 
 fymptoms, inftead of abating, become 
 more violent ; and the event of the difeafe 
 is of courfe rendered more doubtful, 
 
 In this fituation, when no probability 
 
 remains of fuccefs from the employment 
 
 T 4 of 
 
 * By fomt writers, this praftice has been confidered 
 as hazardous ; but I find it recommended by others 
 to whom much credit is due, particularly by the late 
 Dr Monro. See his works, 4to edition, p. ^^g. 
 
5^6 Of Hernia . Chap.V. 
 
 of the means already mentioned, the divi- 
 iion of the parts producing the ftriclure is 
 then our only refource. 
 
 This, it may be remarked, is one of the 
 niceft points in pradice that a furgeon has 
 ever to determine upon : I mean the exacl 
 period at which, in cafes of hernia, the 
 more gentle means ftiould be laid aiide, and 
 the operation be put in pradice. Jf a fur- 
 geon, without having given a full trial to 
 all the ufual remedies, fliould early in the 
 diforder proceed to the operation, and it 
 unfortunately it fliould not fucceed, he 
 would probably be blamed by the friends 
 of the patient as the principal caufe of his 
 death ; and again, even allowing a recovery 
 to be obtained, he is apt to be blamed, not 
 only by his brethren of the profeflion, but 
 by the patient himfelf, for having made him 
 fuffer an unneceiTary degree of pain. 
 
 In fuch a fituation a praclitioner often 
 iinds himfelf much embarrafied. But we 
 ought to be dire(5ted here, as in every cri- 
 tical cafe we are employed in, by the refuk 
 pf experience only j and if this rule is ad- 
 hered 
 
Sed. I. Of Hernis, 297 
 
 hered to, inflead of tedious delays ufual in 
 every cafe of ftrangulated hernia, we will 
 have recourfe to the operation much earlier 
 than is ufually done. 
 
 This operation, as is the cafe indeed with 
 every otherof equal importance, is no doubt 
 attended with fome hazard j but the danger 
 accruing from it has by mofl pracflitioners 
 been more magnified than it ought to be : 
 For although no perfon of charader can in 
 any cafe of hernia be fuppofed to have re- 
 courfe to it before other means have been 
 tried; yet fo far as from experience I am 
 able to judge, the rifk attending the dif- 
 order itfelf when the operation is long de- 
 layed, is infinitely greater than is commonly 
 experienced from the effeds of the opera- 
 tion confidered abftradedly. 
 
 Were we able from the attending fymp- 
 toms to determine the exacft period at 
 which the operation ought to be perform* 
 ed, no kind of difficulty would occur from 
 it ; but this is fo far from being the cafe, 
 that the mofl experienced praditioner can- 
 not with any certainty decide upon it. In 
 
 fome 
 
298 -' Of Hernia,, Chap. V. 
 
 fome inftances, hernias with every fymp* 
 torn of ftrangulation, continue for fix, 
 eight, or ten days ; and after all, tlie pro- 
 truded parts are at length replaced, and the 
 patient does well ; and in many ficnilar 
 cafes when the operation has been the 
 means of relief, although the very word 
 fymptoms have fubiifted for feveral days, 
 yec on laying the 'parts open, no appear- 
 ances either of inflammation or gangrene 
 have been detedted. 
 
 On other occafions, again, the fame fet 
 of fymptoms, with perhaps no greater de- 
 gree of fwelling or tenfion in the parts 
 afFedled, end fatally in a very fhort fpace 
 of time. In fome fuch inftances, the ra- 
 pid progrefs of the diforder is very furpri- 
 {ing; the fpace of eight- and-forty hours 
 hardly intervening, from its firft attack 
 till the patient's death : I have even known 
 the inteilines become perfe(5lly gangrenous 
 in the courfe of one day from the time of 
 their firft expulfion. 
 
 Every pradltioner muft be fenfible, that 
 this is the real flate of the queftion j and if 
 
 it 
 
Se<f^. I. Of Henih-e. 299 
 
 it is fo, ic muft at once become evident, 
 that confiderable delays mufl in fuch 
 critical circumilaRces be always attended 
 with great hazard i and as the real dan- 
 ger to be apprehended from the operation 
 itfelf, is trifling when compared to the 
 rifli which long delays ufually produce, it 
 ought therefore, 1 think, to be laid down 
 as an eflablifhed maxim, Always to pro- 
 ceed to the operation, if in the fpace of a 
 very few hours blood-letting and the other 
 remedies pointed out, do not prove effec- 
 tual. Two or three hours at fartheft, even 
 when the afiiflance of practitioners is early 
 applied for, is perhaps the greateft length 
 of time that ihould ever be confumed in 
 trials of this nature. 
 
 In the treatment of hernias, it is certain, 
 that French furgeons are ufually more fuc- 
 cefsful than the generality either of Ger- 
 man or Britifh praditioners ; and £q far as 
 I know, no reafon can be affigned for the 
 difference, but that the French in almoft 
 every inflance proceed more early to the 
 operation than the furgeons of almoft any 
 
 other 
 
300 Of Hernia » Chap. V. 
 
 other nation. They will thereby, no doubt, 
 perform ic frequently on patients who 
 might have recovered by moregentle means; 
 but any inconvenience arifingfrom this cir- 
 cumftance to a few, is fully compenfated by 
 the number of lives which mud be faved by 
 having recourfe to the operation in due time, 
 and which in all probability would other- 
 wife have been loft. 
 
 Although for very obvious reafons the 
 reduclion of every cafe of hernia ought to 
 be attempted when that can be done with 
 propriety, yet it frequently happens that 
 particular circumftances occur which ef- 
 fe<5^ually debar us from every refource of 
 this nature. 
 
 When once a hernial fwelling has been 
 
 properly reduced, it is in general in the 
 
 patient's power to prevent any return in 
 
 future, by keeping a proper bandage con- 
 
 llantly applied to the opening from whence 
 
 the parts were protruded. But it often 
 
 happens from inattention to this circum- 
 
 ftance, that ruptures which might at firfl 
 
 Jbave been eafily cured, come at laft by 
 
 repeated 
 
Seel. I. OfHernU, 301 
 
 repeated defcents, and by the great quan- 
 tity of parts that fall down, to form tumors 
 of fo great a magnitude, in proportion to 
 the opening through which they were pro- 
 truded, that no art can replace them by the 
 more limple means of reduclion. 
 
 Independently, too, of the great degree 
 of bulk to which tumors of this kind fome- 
 tiraes arrive, fuch adhefions frequently take 
 place, between the vifcera forming the 
 fwelling and the furrounding parts, as 
 render their return altogether impradli- 
 cable by any other means than by the 
 operation. By this lad mode, indeed, al- 
 moft every cafe of hernia may be reduced ; 
 but however necefTary this operation may 
 be when a patient's life is in danger, as 
 it is always attended with fome degree of 
 rilk, it ought never to be put in pradlice 
 where fymptoms of ftrangulation do not 
 aiflually exift. 
 
 In that chronic ftate of hernia we have 
 been juft defcribing, although by interefted 
 and ignorant pra(5litioners the operation 
 has been often propofed as a radical cure, 
 
 yet 
 
o 
 
 2 Of Heniics. Cli a p . V* 
 
 yet no furgeon of characfter would in fuch 
 circutnltances ever think of advifing it; He 
 would reft facisfied with preventing any 
 accumulation of feces in the inteftines, by 
 prefcribing a proper diet and the occa- 
 iional ufe of gentle laxatives ; and with 
 obviating any inconvenience which might 
 arife from the weight of the tumor, by 
 the application of a proper fufpenfory ban- 
 dage. 
 
 By thefe means alone, large tumors of 
 this kind are often rendered very fupport- 
 •able for a great length of time ; the circu- 
 lation of the parts contained in the fwell- 
 ing goes freely and regularly on, as well 
 as the periftaltic motion of fuch parts of 
 the alimentary canal as have been protru- 
 ded ; and hence it is that we have many 
 inflances of large portions of the gut fall- 
 ing down even to the bottom of the fcrotum, 
 and continuing there for a great number of 
 years without producing any interruption 
 whatever to the ufual difcharge by ftool. 
 
 in this fituation, therefore, of the difeafe, 
 the operation can never become admiflible* 
 2 Bur 
 
Sed. I. Of Henna, jdj 
 
 But although people labouring under this 
 ftate of the complaint, do frequently en- 
 joy very good health, and fometimes feel 
 little or no inconvenience from the fwellr 
 ing, yet it mud not be fuppofed that their 
 iituation is altogether free from danger: 
 On the contrary, it is very certain, that 
 on many occafions, fweliings of this kind 
 which have fubfifted for a great length of 
 time w^ithout being produ(5live of much 
 trouble, do at laft inflame and turn painful, 
 fo as to produce every bad fymptom com- 
 monly obferved from the real ftrangula- 
 tion of a gut. As long, too, as a fwelling 
 of this nature remains, as the opening 
 through v^rhich the parts have been pro- 
 truded is thereby effedlually prevented from 
 clofing, fo the patient is always liable to 
 defcents of other portions of intefline which 
 have not formerly been down, and which 
 may be produdlive of the moft fatal fymp- 
 toms. But what we here wifh to eftablifh 
 is, that till once thefe bad fymptoms do 
 adually occur, either from an afFedion 
 of that part of the gut which has been 
 
 long: 
 
304 Of Hernia, Chap. V. 
 
 long down, or of a portion more recently 
 protruded, no fuch operation as the one in 
 queftion ought to be employed. All that 
 can be done with propriety in fuch cafes, 
 is, to fit the patients with proper fufpen- 
 fory bandages ; to warn them of the rifk 
 they are conftantly liable to ; and to cau- 
 tion them againft violent exercife, particu- 
 larly leaping, and every fudden exertion. 
 
 Although with regular practitioners this 
 circumftance cannot require much difcuf- 
 fion, yet the public at large is much in- 
 terefted in it. The former know well, thac 
 the operation fliould not be performed in 
 any cafe of hernia where violent fymptoms 
 do not render it neceflary ; but the latter, 
 by not being able to judge of the various 
 circumftances which ought to be taken 
 into confideration, are too frequently im- 
 pofed upon by that numerous fet of Itine- 
 rants with which every country abounds. 
 By thefe a variety of operations are put 
 in pradlice for performing what they call 
 a radical cure of thefe diforders; by which 
 2 they 
 
Sed.I. Of Hd mice, 305 
 
 they mean to fay, a prevention of future 
 defcents. 
 
 But as no remedy with which we are 
 acquainted, a well adapted trufs only ex- 
 cepted, can be depended on for this pur- 
 pofe ; and as all the other means put in 
 pra(flice for it^ are not only painful, but in 
 general are producftive of much danger ; 
 the magiftracy of every community ought 
 to interfere in fupprelling them. 
 
 The obje(fL in tiew by every attempt of 
 this nature, is, either to etfeduate the entire 
 deftru(flion of the hernial fac, or at leaft to 
 procure an accretion of its fides ; which, 
 by fuch as are ignorant of the anatomy of 
 the parts concerned, has been confidered as 
 capable of preventing any returns of the 
 diforder in future j and for the produc- 
 tion of which, various methods have been 
 invented. 
 
 In order to effedl a total deftrudllon of 
 the fac, our forefathers employed not only 
 the knife, but the potential and even ac- 
 tual cauteries ; and with a view to pro- 
 duce a firm union of its fides, which was 
 
 Vol. L U confidered 
 
3o6 Of Herri-Ice. Chap.V. 
 
 confidered as equally efFedual, it was af* 
 terwards propofed by praditionersofmore 
 tender feelings, to employ the needle and 
 ligature, or what was termed the Royai 
 Stitch : and for the fame purpofe was in- 
 vented the famous punihwi aiireum^ which 
 was performed in the following manner. 
 After reducing the inteflines into the abdo- 
 men, the fac was laid bare with a fcalpel ; 
 and a piece of gold wire being paffed 
 round its upper end, the wire being like- 
 wife made to include the fpermatic cord, 
 it was then ordered to be twifted with a 
 pair of forceps to fuch a degree of tight- 
 nefs as to prevent the defcent of the gur, 
 but not to interrupt the circulation in the 
 fpermatic cord *. 
 
 But none of thefe methods being found 
 to anfwer, for even the adual cautery, when 
 carried perhaps to the depth of the bone 
 itfelf, did not fecure the patient againfh 
 
 a 
 
 * For a more particular account of tliefe various 
 modes of pra£lice in the different kinds of hernia as 
 employed in former times, fee the writings of Albu- 
 cafis, Paulus j^Lgineta, Fab, ab Aquapendente, Hif- 
 danus, Parey, &c. 
 
Seel. I. Of Hernia, 307 
 
 a return of the diforder, our modern pre- 
 tenders have therefore ventured to improve 
 upon the ignorance of ancient practitioners, 
 and adlually go the length of deflroying 
 not only the hernial fac, but even the 
 teflis alfo : without any knowledge of the 
 anatomy of the parts, and having no 
 charadcrs to fulFer from whatever confe- 
 quences may enfue, they proceed without 
 fear ; and, by promifing all that patients 
 can hope for, they are fure to be every 
 where well received. In confequence of 
 this, in every large tov/n, many operations 
 are performed by them; numbers accord- 
 ingly are for certain mutilated, and many 
 thereby even lofe their lives. Their me- 
 thod of proceeding is fhortly this : They 
 lay bare the hernial fac, and having redu- 
 ced the prolapfed parts, a ftrong ligature is 
 pafTed round both the fac and fpermatic 
 cord, and is drawn fo tight as to defcroy 
 effedually, not only the paffage along the 
 fac, but the cord itfelf, and of courfe the 
 teflicle. On fome occafions matters go no 
 farther j but on others, fiich a degree of 
 U 2 inflam- 
 
3o8 Of Her nice. Chap. V. 
 
 inflammation has been Induced, as to ter- 
 minate in the patient's deftrutflion. 
 
 If any of thefe means, however, was to 
 be prod'jcflive of the effedl propofed. viz. 
 the prevention of every future defcent of 
 inteftine. the riflv incurred would be in 
 fome meafure com pen fated by the advan- 
 tage received : But the fa6l is much other- 
 wife ; for unlefs a trufs be kept conftantly 
 appUed, the patient continues liable to a 
 return of the diforder in nearly the fame 
 degree as if no operation had been per- 
 formed, liven the operation for the hernia 
 itfelf, does not, as has been fuppofed, for- 
 tify the parts agalnft a return of the dif- 
 order, the continued ufe of a trufs being 
 juft as ncceflary after that operation as if 
 it had not taken place. 
 
 I have dv.'clt longer on this circum- 
 fiance than may be thought neceffary by 
 thofe who are much converfant in this part 
 of practice ; but as it is certain, that even of 
 lace years much niifchief has been done by 
 Itinerants in the various fpecies of hernia, 
 and as they flill continue to impofe upon 
 
 the 
 
m-cnc VllE 
 
 ^y^^_^. 
 
 J^H 
 
 "^/Se/Z^^y^i 
 
S^d. T. Of He mice o 3^39 
 
 the public, I thought it necelTary to put 
 the unwary on their guard againfl: the ef- 
 fe(5\s of their knavery and ignorance. 
 
 In Place VIII. are reprefented a variety 
 of trufTes for different fpecies of hernia. 
 Thofe here delineated are intended for 
 the more ufual kinds of hernia, viz. the 
 inguinal, crural, and umbilical. . When 
 others are wanted for particular parts, 
 fome ingenious tradefman in that line of 
 buHneft fhould be applied to, with di- 
 rections to fit the inflrument with the 
 nicefl exacflnefs to the parts for which it 
 is intended. Indeed, the good effedls of 
 every bandage for this complaint, depend 
 fo much upon the exaclnefs with which it 
 is made to iit, that without the utmoft 
 nicety in this refpecl, it mufh always do 
 more harm than good ; for the fole pur- 
 pofe of a bandage in cafes of hernia, is to 
 prevent effetlually the falling down of 
 fuch parts as have been newly replaced: If 
 therefore the pad or bolfler of the bandage 
 does not bear properly againfi the opening 
 iipon which it is placed, a portion of guc 
 U J may 
 
3IO Of Hernia, Chap. V, 
 
 may flip out, and be thus materially in- 
 jured by the preiTare of the pad. I have 
 met with difFerent inftances of this kind* 
 where bandages by not being exacftly fitted 
 did much mifchief ; and every pradlitioner 
 mud have obferved theifi: it is therefore a 
 matter of the firfl importance, that tradef- 
 men be ordered to pay much attention 
 to this circuinflance. Every bandage 
 ufed for this purpofe ought to be of the 
 fleel-fpring kind ; for thofe compofed of 
 linen and other foft materials, can never 
 be kept properly applied. Even in infancy 
 the flecl bandages, when properly made, 
 are in general ufed with eafe and fafety ; 
 But at any rate, when they cannot be got 
 to apply exa(5lly, which in early childhood 
 is fometimes the cafe, no dependence ouglit 
 to be placed upon any other ; for they al- 
 ways fret and gall the parts to which they 
 are applied, and 1 never knew them in any 
 one inflance to anfwer the purpofe. 
 
 Elaving premifed thefe general obferva- 
 tions, which relate equally to every variety 
 of the difarder, and by v;hich frequent 
 
 repeti^ 
 
Sfid. II. Of HernU» 311 
 
 repetitions will be rendered unnecefTary, 
 we {hall now proceed to the more parti- 
 cular conlideration of the different fpecies 
 of hernia j and firil of the Bubonocele. 
 
 SECTION II. 
 
 Of the Bubonocele. 
 
 nnOGETHER with the general fymptoms 
 of ftrangulated hernia which we have 
 lately enumerated, and to which we muft 
 here refer, the particular appearances of the 
 bubonocele, or inguinal hernia, are, a fofc 
 fomewhatelaftic fweliing, beginning in the 
 groin, and defcending by degrees into the 
 fcrotuminmen,and into the labia pudendi, 
 in women. When a portion of gut forms 
 the tumor, it commonly feels tenfe, and 
 this always in proportion to the degree of 
 ftridlure that occurs in the opening of the 
 tendon; and when any inflammation takes 
 place, the lead degree of handling or pref- 
 fure always gives pain. 
 
 When the hernia contains omentum 
 
 only, the fweliing is both more fofc, com-^ 
 
 U 4 preiTible^ 
 
51 2 Of Hcrniiz, Chap. V, 
 
 preflible, and more unequal, than when 
 gut alone is down ; the fcrotum becomes 
 more oblong, and of courfe lefs round, than 
 in an inteftinal hernia; and when the quan- 
 tity of omentum is large, it is alio much 
 more weighty than a gut rupture of the 
 fame fize : But in many cafes, perhaps in 
 the greatefl proportion of all hernial fwell- 
 ings, the tumor is compofed of both gut 
 and omentum ; and then the diftinguifli- 
 ing fymptoms of each can never be fo 
 clearly marked. In books, various fymp- 
 toms are enumerated, for diflingviiiliing 
 the contents of every fpccies of hernia j 
 but whenever the cafe is any degree com- 
 plicated, every candid practitioner mufl: 
 acknowledge, that no certainty as to this 
 point can be obtained till the tumor is 
 fairly laid open. 
 
 As there are fome diforders with which 
 the inguinal and fcrotal hernia may be 
 confounded, pracftitioners ought to be as 
 much acquainted with their characferiflic 
 marks as poflible. Thefe complaints are, 
 glandular or other fwellings in the groin, 
 
 whether 
 
Sed. 11. QfEernliS, 313 
 
 whether from the venereal difeafe or any 
 other caufe; that fpecies of fwelUng termed 
 Hernia Humoralis ; and all the difFerenc 
 kinds of hydrocele. , 
 
 The venereal bubo and other fwellings 
 in the groin, are readily diftinguiflied from 
 hernia, not only by the abfence of all the 
 general fymptoms of hernia, but by thac 
 incompreffible hardnefs with which all 
 fuch fwellings are. at firft attended, and 
 by the fludluation of matter which in their 
 fuppurated (late is always obfervable. 
 
 In the hernia humoralis, or fwelling of 
 the tefticle, the hardened and enlarged ftate 
 of the tefticle itfelf, as well as of the epidi- 
 dymis ; their being exquiiitely painful to the 
 touch ; the tumor being remarkably heavy 
 in proportion to its bulk; and the fperma- 
 tic procefs being commonly very free from 
 fwelling ; are in general pretty certain marks 
 of diftindlion. In the hernia humoralis, 
 too, the inteftines are free andunobftrucfled, 
 and the other general fymptoms of hernia 
 as formerly pointed out are wanting. 
 
 In the hydrocele of the ti^nica vaginalis 
 
 teftis, 
 
314 . Of Hermct Chap. V. 
 
 tcftis, the tuinoi' in general is more equal 
 to the feel than in hernia : in the former, 
 the fwelUng always begins in the under part 
 of the fcrotum, and proceeds upwards : 
 "whereas the very reverfe occurs in hernias. 
 Except in cafes of very enlarged hydrocele, 
 the fpermatic procefs is always perfectly 
 free and di(lin6t ; whereas in every cafe of 
 hernia where the rumor defcends to the 
 icrotum, the fpermatic cord cannot in any 
 part of its courfe be diflinguiQied. In a 
 hydrocele, a flucluation of a fluid is diftin- 
 guifhable ; in a hernia it is otherwife. 
 
 From the anafarcous fwelling of the 
 fcrotum, or hydrocele of the dartos as it 
 is termed, hernia is very readily diftin- 
 guiihed ; and indeed the means of diflinc- 
 lion are fo obvious, that they need not be 
 here enumerated ; but there is ianother fpe- 
 cies of hydrocele, viz. the hydrocele of the 
 fpermatic cord, which on fome occalions it 
 is no eafy matter to diftingufh from her- 
 nia, and which therefore requires particu- 
 lar attention. 
 
 The fpecies of hydrocele, where the 
 
 water 
 
Seel. II. Of Hernia. 315; 
 
 water is collected in one or more cells of 
 the fpermatic procefs, now and ihen be- 
 gins in the under part of the cord, and 
 proceeds upwards ; and in fuch cafes, this 
 circumftance alone is a fufficient means of 
 diftindlion between it and hernia, in which 
 the fwelling always proceeds from above 
 downwards ; but it fomerimes happens, 
 that the fwelling in this kind of hydro- 
 cele begins even within the opening in the 
 abdominal mufcie, and by degrees falls 
 downwards. In fuch inftances, it is alto- 
 gether impoffible from the ftate of the tu- 
 mor merely, to fay whether it is the one 
 difeafe or the other. The general fymp- 
 toms of hernia, fuch as pain and tenfion 
 of the abdomen, obftrudted inteftines, Sec. 
 muft be particularly attended to : and as 
 thefe do not occur in any fpecies of hy- 
 droceles when they happen to take place 
 they will commonly throw much light 
 on the real nature of the difeafe. In 
 fome cafes, however, thefe and every 
 other means of diftindlion are wanting; 
 iDut even in fuch circumftances a prudent 
 
 pradi- 
 
3 1 6 Of Herniis, Chap. V. 
 
 pra6litloner will never run any rifk, either 
 of hurting his patient, or of affedling his 
 own reputation ; which the miftaking a 
 Hernia for a Hydrocele, and treating it as 
 fuch, muft always do; and which, to the 
 difgrace of Surgery, has on fome occafions 
 adtually happened. 
 
 In all fuch cafes, where any degree of 
 doubt occurs, as well as in every cafe of 
 tumor in the tefticle where the nioft per- 
 fe(5l certainty is not obtained, and when 
 it is neceffary to have recourfe to an ope- 
 ration, the furgeon ought to proceed as if 
 the diforder was a real hernia : By doing 
 ^o^ every rifk will be avoided ; and on the 
 tumor being laid cautiouily open, the true 
 nature of the difeafe will be then rendered 
 evident, and the praditioner accordingly 
 will be at liberty to apply the means bed 
 fuited for its removal. Whereas by adopt- 
 ing a contrary method, and by treating as 
 a Hydrocele what afterward turns out to 
 be a true Hernia; independent of any in- 
 jury to his own reputation, he runs a very 
 great rifk of deftroying his patient. 
 
 In 
 
Se<5t. II. Of Herma, 3 1 y 
 
 In the treatment of the Bubonocele, 
 when the various means we have recom- 
 mended when treating of hernia in gene- 
 ral are employed without fuccefs, the fur- 
 geon is then under the neceffity of proceed- 
 ing to the operation ; and the method of 
 doing it is this. 
 
 A table of a convenient height being 
 placed in a proper light, the patient muft 
 be laid upon it with his head and body 
 almofl horizontal, whilft at the fame time 
 his buttocks are fomewhat elevated by pil- 
 lows laid beneath them. The legs hang- 
 ing over the edge of the table ought to be 
 feparaced fo as to admit the operator be- 
 tween them ; and fhould in that fituation 
 be firmly fecured by an affiftant on each 
 fide, who fhould take care to keep the 
 thighs fo far raifed, as to relax all the ab- 
 dominal mufcles. 
 
 In order to afford as ipuch empty fpace 
 as poffible for the return of the protruded 
 parts, the patient fhould be advifed to 
 empty his bladder entirely; and the parts 
 having been previoufly fhaved, an incifion 
 
 muft 
 
31 8- Of Hernia, Chap. V. 
 
 muft now be made with a common 
 round- edged fcalpel through the fkin and 
 part of the cellular fubftance, beginning 
 at leaft an inch above the fuperior end of 
 the tumor, and continuing it down to 
 the mod depending part of the fcrotum. 
 Even although the tumor does not extend 
 to the bottom of the fcrotum, the parts 
 fliould be laid open in this manner. By 
 a free external incifion we are enabled to 
 finifli the operation with more eafe and 
 freedom than when the firft opening is not 
 fo large; it does not produce much more 
 pain than a fmall incifion; and by being 
 continued to the bottom of the fcrotum, 
 the matter produced in the upper part 
 of the fore is prevented from collecft- 
 ing below, which it is oiherwife ready 
 to do. 
 
 The operator now goes on to divide 
 flowly the reft of the cellular fubftance, 
 together with fome tendinous kind of 
 bands, which, unlefs the diforder is very 
 recent, are univerfally met with, either 
 loofe upon the furface of the hernial fac, 
 
 or. 
 
Sedl. II. Of Herm<:e, 315 
 
 or, on fome occauons, paffing as it were 
 into its fiibdance. Even this external in- 
 cilion of the teguments ought to be made 
 with great caution: For although in by- 
 much the greatefl proportion cf hernial 
 fwellings, the fpermatic vefTels lie behind 
 the protruded parts, yet on fome occafions 
 they have been found on the anterior part 
 of the tumor; fo that in order to avoid 
 the rifk of wounding them, as foon as the 
 fkin is divided the remainder of the ope- 
 ration ought to be done in the mod cau- 
 tious manner, care being taken to avoid 
 every large blood- veiTel that makes its ap- 
 pearance. 
 
 This circumftance of the prolapfed parts 
 getting down behind the fpermatic velTels, 
 has never, fo far as I know, been taken 
 notice of in books; it muft therefore be a 
 very rare occurrence. As I met with ir, 
 however, in one cafe, where the facfl was 
 exceedingly evident, the poffibility of its 
 happening I have therefore no reafon to 
 doubt. If we attend only to the ufual con- 
 formation of thefe parts, the hernial fac, 
 
 we 
 
320 Of Htrnia, Cliap.V. 
 
 we would fay, ought never to get behind 
 the fpermatic cord: But we know well^ 
 that in no part of the human body is na- 
 ture more apt to defert her ordinary courfe, 
 than in fome circumftances relating to the 
 tefticles and their blood veffels. We ha-ve 
 already obferved, that till near the period 
 of delivery, the tefticles continue in the 
 abdomen; and about that time, fall down 
 in a gradual manner to the fcrotunt. 
 Many inftances, however, occur, of both 
 teftes remaining in the abdomen through 
 life: Sometimes one remains, and the 
 other falls into the fcrotum. On other 
 occafions, one or both fall into the groin, 
 and never proceed farther; a circumftance 
 which every young pracflitioner fliould be 
 aware of, as inftances have occurred of a 
 tefticle remaining in the groin being mif- 
 taken for a hernia, and of much pain and 
 diftrefs being produced by different at- 
 tempts made for their redudion. Now, 
 if fuch varieties as thefe occur in the me- 
 chanifm of thefe parts, why may not na- 
 ture in fome inftances produce fuch a con- 
 I formation' 
 
Sedt. II. Of Hernia » ^21 
 
 formation as may, in the event of a her- 
 nial fac falling into the fcrotum, bring the 
 fpermatic cord, and even the tefticle itfelf, 
 into a fituation anterior to the protruded 
 parts? I £hall not here enter into the dif- 
 euffion of the manner in which fuch a 
 circumftance may be produced; but, as I 
 am certain that the fa(5l has happened, and 
 as it may therefore occur again, I confider 
 it as an additional argument for the pro- 
 priety of dividing the hernial fac in the 
 cautious manner here diredled *. 
 
 In making this firfl incifion of the ikin^ 
 it is ufual to do it by pinching up the te- 
 guments, and then dividing them vs^ith a 
 fcalpel; but no furgeon of fleadinefs and 
 dexterity will ever think it neceflary to 
 proceed in this manner: for this iqcifion 
 of the fkin is done with much mor^ neat-!- 
 
 Vol. I. X nefs, 
 
 * Since this went to the prefs, I find that a fimilar 
 inftance is recorded by Le Dran, in his Treatife on 
 Rupturesy of the fpermatic veflels having been found 
 on the anterior part of a bubonocele. — Such a fitua- 
 tion,' therefore, of thefe veflels, is perhaps more frequen| 
 ^an is commonly imagined. 
 
322 Of Hernia. Chap. V. 
 
 nefs, and with equal fafety, by the opera- 
 tor grafping the tumor wich his left-hand, 
 in fuch a manner as to render the tegu- 
 ments on the anterior part of it as tenfe as 
 poffible, while with the fcalpel in his right- 
 hand he divides the ilcin from one end of 
 the fwelling to the other. 
 
 The divifion of the fliin and cellular 
 fubftance being continued in the manner 
 diredled till the fac is laid bare, an open- 
 ing mud be made in it fo as to bring its 
 contents into view; and the mod fafe place 
 for fuch an opening is, not about the mid- 
 dle of the tumor, as is commonly directed, 
 but as near to the under point of it as pof- 
 iible; It is here done with as much eafe as 
 in any other part; and befides, the gut is 
 feldom if ever found jufl at the bottom of 
 the fac, which is commonly occupied with 
 a quantity of bloody ferum ; fo that the 
 rifk of wounding it there is much lefs thaa 
 in any other part of the fwelling. In ma- 
 king this perforation into the fac confifta 
 the greateft nicety in the operation, the 
 •atmofl caution being neceiTary to avoid 
 
 wound- 
 
Sed. II. Of HerniiS. %%i 
 
 wounding the parts protruded from the 
 abdomen. Good eyes and a fteady hand 
 are in no operation more requifite than in 
 this: With thefe, any practitioner acquaint- 
 ed with the anatomy of the parts may be 
 fiire of doing the operation properly, and 
 without them the beft anatomill muft un- 
 doubtedly go wrong. 
 
 With the fame fcalpei that divided the 
 ildn and cellular fubftance, the operator 
 muft proceed {lowly-, dividing one fibre of 
 the fac after another, till there is reafon to 
 think that the whole fubftance of it is cut 
 through. This may be always difcovered 
 by means of the blunt end of a probe: If it 
 pafles in eaftly, we may conclude with cer- 
 tainty that the fac is divided; and if it 
 does not, the inciftou muft be continued in. 
 the fame gradual manner fomewhat far- 
 ther, when the fame trial with the probe 
 muft be again made. 
 
 In profecuting this divifion of the fac, 
 a good deal of ailiftance is obtained from 
 the ufe of a fmall fharp-pointed diredlory, 
 open at^the extremity, as is reprefented ia 
 
324 Of Hernia, Chap. V, 
 
 Plate IX. fig. 3. By pufliing the end of 
 this mftrument below fome of the fibres of 
 the fac, they are thereby feparated from the 
 parts underneath, and may be thus divi- 
 ded with more fafety than in any other 
 manner; and in the fame way the remain- 
 ing parts of the fac muft be divided, til! 
 this part of the operation is finiflied'^'. 
 
 In almoft every cafe of hernia where 
 the tumor is confined to the groin, and 
 even where the fwelling extends to the 
 fcrotum if the pares are recently protru- 
 ded, the hernial fac is found very thin, and 
 in fuch cafes is always foon cut through ; 
 but it is necefTary for the information of 
 young praditioners, to obferve, that in 
 hernial fwellings of long fhanding, the fac 
 frequently becomes fo very thick, as to 
 require much more difTecflion than be- 
 ginners 
 
 * In the 4th Volume of Memoirs of the Paris Aca- 
 demy of Surgery, there is a very ingenious paper on 
 Herniae by Monfieur Louis. But although there are 
 ?iany ufeful obfervations communicated in this trea- 
 "*ife, Mr Louis in one point I think has gone far wrong, 
 in ridiculing that degree of caution fliown by fome 
 
 fur= 
 
Se£l.II. . Of Hernia, 325 
 
 ginners commonly expecfl : By going on, 
 however, in the cautious manner we have 
 direded^ every rifk of wounding any ma- 
 terial part may be avoided. 
 
 As foon as an opening is made quite 
 through the fac, a circumftance of which 
 we are made certain, as was already re- 
 marked, by a probe pailing eaQly in, it 
 ought then to be farther enlarged, till it is 
 X3 of 
 
 furgeons In dividing the hernial fac : The divlfion of 
 the fac, he fays, is attended with fo Httle difEculty, that 
 he does not confider it as different in that refpedl from 
 the firft external incifion of the flcln. His words are* 
 ^' Jamais le fac ne m'a donne ni plus de peine, ni 
 plus d'embarras que la peau; on divife, pour ainfi 
 dire, celle-ci du premier trait, et le fac du fecond. " 
 In the hands of fuch an expert operator as Mr Louis, 
 •the fcalpel even In this manner may be fo managed 
 as to do no harm, but with the general run of 
 pra£litioners much mifchief would be produced by 
 proceeding in this part of the operation fo rapidly as 
 is here diredled. And when we refledi that the dif- 
 ference of a few feconds in the courfe of the operation, 
 is all that could be gained by the greateft difpatch we 
 can employ, little doubt, I thinic, can remain as to the 
 propriety of proceeding through every part of it in 
 $Jig moft deliberate manne^r. 
 
^iG Of Hernia, Chap.V. 
 
 of fuch a fize as to admit the fore- finger 
 of the operator's left-hand. 
 
 The finger being now introduced, is to 
 he ufed as a director for entering the nar- 
 row bkmt-pointed billoury, reprefented in 
 l^late VII. with which the furgeon is to di- 
 vide the hernial fac along its whole length 
 from below up to the opening in the ex-, 
 ternal oblique mufcle. By means of the 
 finger as a diredlor for the biftoury, this 
 p^rt of the operation is performed with 
 perie^t fafety; and the biftoury'here deli- 
 neated, renders the many complex inftru- 
 ments formerly employed not only for 
 this part of the operation, but for the 
 fubfequent divifion of the tendon, quite 
 unnecefTary. 
 
 On laying the fac open at the bottom^ 
 a quantity of coloured fluid always rufhes 
 out, and the protruded parts now come 
 fully into view: If a portion of gut is down, 
 and is not much entangled with omentum, 
 by being now fet at liberty it pufhes out 
 immediately on the fac being opened; 
 thereby giving the appearance of having 
 
 been 
 
Sed. II. Of Herni(^, 327 
 
 been coUedled in a larger quantity, than the 
 iize of the tumor gave reafon to expe(ft. 
 
 The portion of gut found in hernial 
 fwelUngs is very various, no part of the 
 intellinal canal being entirely exempted 
 from falling down. Hitherto the ileum 
 has been commonly fuppofed to form the 
 fubflance of the greatelt proportion of 
 fuch tumors; later and more accurate 
 obfervation, however, renders it probable, 
 that the csecum, appendix vermiformis, 
 and part of the colon, are perhaps as tre- 
 -quentiy contained in herniary facs as any 
 other portion of the gut. 
 
 The fac being laid fully open, the parts 
 contained in it ought now to be exammed 
 with the niceft attention, in order to dif- 
 cover whether they are all found or not ; 
 and if upon an attentive infpedlion they 
 are found to be found, that is, if they are 
 not evidently in a gangrenous ftate, even 
 although they do feem to be confiderably 
 inflamed, every endeavour fliould be ufed 
 to get them immediately returned into the 
 rabdomen. 
 
 X 4 la 
 
328 of Hernia. . Cliap.V* 
 
 In making the redudllon, whether in- 
 tefline or omentum, or a portion of each, 
 have been found contained in the fwel- 
 ling, thofe parts of them which appear to 
 have come lafl out, ought to be firft 
 puflied back ; the diiEculty and trouble 
 of returning them being thereby much 
 lefTened : And in making the redu(5lion, 
 it both anfwers the purpofe better, and is 
 lefs Ukely to do mifchief, to apply the fin- 
 gers to that part of the intefline connedled 
 with the mefentcry than to the convex 
 part of the gut. While the redu(5lion is 
 going on, the patient's thighs and loins 
 fhould be ftill more elevated than they 
 were dufing the preceding fteps of the 
 operation ; as this pofture of thefe parts 
 tends much to facilitate the return of 
 the protruded inteftines to the abdo-^- 
 men. 
 
 When the difeafe is recent, and the parts 
 have not been frequently down, it fome- 
 times happens, that by pulling out a little 
 more of the gut than was formerly in the 
 fac, any obftrudion which occurred to its 
 
 being 
 
Sed. IT. Of Hernia, 329 
 
 being replaced is thereby removed ; and if 
 the protruded parts are not of great bulk^ 
 they may thus be fometimes reduced, with- 
 out any neceflity for enlarging the opening 
 through which they have pafTed from the 
 abdomen : But when upon trial this can- 
 not be done with great eafe, it fhould never 
 be attempted; much more danger being to 
 be dreaded from any degree of force ufed 
 for the reduction of the gut, than can ever 
 occur from finifhing the operation by an 
 enlargement of the opening in the tendon 
 of the external oblique mufcle. 
 
 As the tendon of this mufcle runs in an 
 oblique diredion from above downwards, 
 and as the opening through which the 
 contents of a hernia protrude, is formed 
 merely by a feparation of the tendinous 
 fibres from one another, the diredion of 
 this opening is of courfe the fame with 
 that of the tendon ; that is, it runs fome- 
 "V^hat obliquely from thefpine of the ileum 
 to the OS pubis. 
 
 In enlarging this palTage, then, for the 
 redu(flion of fuch parts as have pafTed 
 
 through 
 
33° Of Hernia, Chap. V. 
 
 through it, as a tranfverfe fedion of the 
 tendon is by no means necefTary, the knife 
 fhould be carried obliquely upwards, fo as 
 merely to continue the natural reparation 
 of the tendinous fibres. 
 
 The finger was recommended as the bed 
 direcflor for the knife in opening the fac, 
 and in dividing the tendon it is equally 
 necefTary. By infinuating the finger into 
 the aperture in the tendon immediately 
 above the protruded parts, the point of the 
 blunt biftoury is eafily introduced upon it; 
 and in this manner, by keeping the end 
 of the finger always a little before the bi- 
 ftoury, the opening may be enlarged to 
 any necefTary extent without any rifk of 
 wounding the contiguous parts. 
 
 In general, a very fmall enlargement of 
 the natural opening in the tendon is found 
 fufiicient for the redudlion of the gut and 
 other parts : But the fize of the opening 
 ought by all means to be fully fufficienc 
 for the end propofed ; for it is better to 
 exceed in making it fomewhat too large, 
 than to run any riik of hurting the parts 
 
Sed. II. Of Hernia. 33 1 
 
 by forcing them through a very fmall 
 aperture. 
 
 If upon introducing the finger any ad- 
 hefions of the gut to the contiguous parts 
 are difcovered, the incifion in the tendon 
 ought to be larger than might otherwife be 
 necefTary, in order that the finger may be 
 freely admitted fo as to deftroy fuch ad- 
 hefions as it can reach ; for unlefs they 
 are removed, complete fuccefs from the 
 operation cannot be expedled. 
 
 Independently of fuch adhefions inter- 
 nally, it frequently happens, by long con- 
 finement in the fcrotum ; preffure ; and 
 perhaps other caufes ; that ftrong adhefions 
 are formed among the parts contained in 
 the fac itfelf ; and before they can be with 
 propriety reduced, it is always necefiTary 
 to attempt to feparate them. 
 
 When adhefions of this kind occur, as 
 they fometimes do, between different parts 
 of the protruded gut, the greateft caution is 
 neceffary in feparating them : But connec- 
 tions of this nature between one portion of 
 Ae inteftinal canal and another, are feldom 
 
 very 
 
j 3 ^ ^f Hernia\ Chap. V. 
 
 very firm, and are commonly eafily fepa- 
 rated by the fingers alone ; and when the 
 connedlion is formed by means of long fila- 
 ments, which is fometimes the cafe, the 
 eafieft method of removing them is to cut 
 them, either with a pair of fcifTars or the 
 bifloury : But when it is found, that one 
 part of a gut adheres fo firmly to another 
 as not to be feparated but with difficulty, 
 it is much better to return the whole even 
 in that flate into the abdomen, than to run 
 the rifk of hurting the inteftine materially 
 by ufing much force. 
 
 When,again,adhefions occur between the 
 gut and the hernial fac, or between the gut 
 and omentum, if the filaments producing 
 the conneclion cannot be otherwife remo- 
 ved, as there is no great hazard in wound- 
 ing the omentum, and ftill lefs in hurting 
 the fac, a very fmall portion of thefe may 
 be diifeded off, and returned with the gut 
 into the abdomen ; and in the fame man- 
 ner, when the omentum adheres fo firmly 
 to the fac as not to be feparated in any 
 other manner, na danger can ever accrue 
 
 froni 
 
Sedl. 11. Of HernU. 333 
 
 from the fac being fomewhat encroached 
 upon. 
 
 The rilk and trouble attending the prac- 
 tice now recommended is nothing, at lead 
 it is very trifling, when compared to the 
 inconveniences that would enfue from lea- 
 ving either the omentum or gut adhe- 
 ring externally to the hernial fac, as is ad- 
 vifed by fome writers when fuch adhe- 
 fions cannot be very eafily divided. The 
 fmalleft portion of gut being left down, 
 would run a great rilk of fuffering byexpo- 
 fure to an unufual degree of cold, and to 
 the effecfls of the external air at the differ- 
 ent dreffings ; and by leaving part of the 
 omentum to protrude through the opening 
 from the abdomen, one great advantage 
 to be expedled from the operation would 
 be loft, viz. the prevention in future of that 
 rilk which a patient with a portion of pro- 
 truded omentum is always liable to, of a 
 piece of gut flipping down, and perhaps 
 of becoming fl:rangulated. 
 . After returning the contents of the fac 
 into the cavity of the abdomen, it has been 
 
 propofed 
 
334 Of Hernia. Chap. V. 
 
 propofed by fome authors, to pafs a liga- 
 ture round the upper part of the fac juft 
 at its neck, with a view, as we are told, of 
 procuring a reunion of its fides, in order 
 that it may ferve as a means of preventing 
 future defcents of the bowels. 
 
 But as fuch a ligature cannot be applied 
 without much riik of injuring, or even 
 of deftroying the fpermatic vefTels, with 
 wbich the poflerlor lamella of the fac is 
 immediately conneded, the pradice from 
 that confideration alone ought to be laid 
 afide ; but in reality it does not appear to 
 be in any degree necefTary, as this very 
 union of the fides of the fac is univerfally 
 produced merely by that degree of inflam- 
 mation which always fucceeds to the divi- 
 fion of it by this operation. 
 
 Hitherto we have recommended the im^ 
 mediate redudion of the contents of hernial 
 tumors upon the fuppofition that they have 
 been only difplaced ; that they have been 
 adhering to one another or to the neigh- 
 bouring parts ; or perhaps that they have 
 4 been 
 
Sea.II. O/HcrtiKt. 335 
 
 been more or lefs in a flate of inflam- 
 mation. But when it appears that this 
 inflammation has already terminated in 
 gangrene, as the return of fuch mortified 
 parts, whether of omentum or inteftine, 
 might be exceedingly hazardous, a greater 
 degree of caution becomes neceflary. 
 
 When the omentum is found in a mor- 
 tified flate, as the excifion of a portion of 
 this membrane is not attended with much 
 rifli, it has been the common pratlice to 
 cut away the difeafed parts ; and in order 
 to obviate any inconvenience from the he- 
 morrhagy which might enfue, we are ad- 
 ■vifed to make a ligature on the found parts 
 previous to the removal of thofe that are 
 mortified ; whilft the ends of the ligature 
 bemg left hanging out of the wound, the 
 furgeon has it in his power to remove them 
 when circumftances appear to render it 
 proper. 
 
 Thefe ligatures on the omentum, how- 
 ever, having frequently been productive 
 of bad confequences, fuch as naufea, vo- 
 miting, cough, fever, pains in the belly. 
 
336 Of Hernlt* . Chap. V. 
 
 and inability to fit ere(ft ; and it having 
 been found by the experience of many in- 
 dividuals, that no hemorrhagy of any im- 
 portance ever occurs from a divifion of this 
 membrane even in a found unmortified 
 {late; fuch parts as have become gangrenous 
 may therefore be freely cut off, and the 
 remaining found parts be afterwards with- 
 out the intervention of ligatures introdu- 
 ced into the abdomen with no rifle what- 
 ever. This is now the opinion of different 
 pradlitioners * : But if it fhould ever hap- 
 pen, on cutting off part of the omentum, 
 that a veflTel of any fize is divided, a liga^ 
 ture may with great fafety be pafled about 
 the veflTel itfelf, without including any of 
 the membrane ; and the ends of it being 
 left long enough to hang out at the wound, 
 
 the 
 
 * A very accurate paper upon this fubjeft may be 
 feen in the 3d Vol. of Memoires de I'Academie Royalle 
 de Chirurgle of Paris, by Monfieur Pipelet, in which 
 feveral cafes are related of the bad effects Droduced by 
 ligatures on the omentum. 
 
 Mr Pott is alfo of this opinion. — Vide Treatif? pu 
 Ruptjires. 
 
Se(fl» II. Of Hernia i 337 
 
 the threads may be afterwards pulled away 
 at pleafure. 
 
 Another circumftancefometimes occurs, 
 too, which renders the removal of part of 
 t^e omentum neceffary ; when a rupture 
 has been of long duration, and a confider- 
 able portion of caul has remained long 
 down, from the prelTure made by the ufual 
 fufpenfory bandage and other circum- 
 flances, it frequently happens that conii- 
 derable quantities of the protruded parts 
 become much thickened, very hard, and 
 collected into lumps. When thefe lumps 
 are not very large, there is no neceflity for 
 removing them, as when fmall they may 
 be returned into the abdomen without pro- 
 ducing any inconvenience ; but whenever 
 it appears to the operator, that by their 
 bulk and hardnefs they might probably do 
 mifchief if reduced into the belly, they 
 ought-as certainly to be cut off as if in a 
 ftate of real mortification. 
 
 When it is determined to remove any 
 part of the omentum, the eafieft and fafeft 
 methoo of doing it is this. The mem- 
 
 VoL. L Y brane 
 
2%S Of Hernia, Chap.V. 
 
 brane ought to be carefully expanded at 
 the part intended to be cut ; and in this 
 flate it is very eafily divided by a pair of 
 thin-edged fcilTars, much more fo indeed 
 than by any other inftrument. When fully 
 fpread out, any turn of the intefhine that 
 happens to be enveloped in it, is at once 
 brought into view, which without this 
 precaution we would run a great rilk of 
 dividing by the fcifTars. 
 
 When, again, a portion of gut is found 
 to be mortified, if it fhould be returned in 
 that (late, a difcharge of feces would cer- 
 tainly take place into the cavity of the ab- 
 domen, as foon as the mortified fpot fhould 
 feparate from the found. In order to pre- 
 vent fuch an occurrence, which would 
 foon terminate in the patient's death, if 
 it is a fmall fpot only that is difeafed, we 
 ought to endeavour by means of a needle 
 and ligature, to connect the found part of 
 the gut immediately above the mortified 
 fpot, CO the wound inrheabdominal parietes. 
 By this means, when tiie mortified part fe- 
 parates, or on its being immediately cut 
 
 out. 
 
§e£l . It. Of Hernia ., 
 
 339 
 
 out, which is perhaps better, the feces are 
 difcharged by the wound ; and different: 
 inftances have occurred, where the lofs of 
 fubftance produced by the mortification 
 was not extenfivCj of the opening into the 
 gut becoming gradually lefs, and at laft 
 healing entirely : But whether the event 
 Ihould prove fo fortunate or not, when- 
 ever a portion of gut is obferved to be com- 
 pletely mortified, it ought by all means to 
 be fecured by a ligature to the parts mod 
 contiguous to the wound. 
 
 And farther, when the mortified portion 
 of gut is of great extentj and includes, fo far 
 as it goes, the whole circumference of the 
 intefline, the gangrenous parts of it oughe 
 to be cut out at once ; and if the quantity 
 thus taken away is not fo confiderable as 
 to prevent the ends of the gut from being 
 brought into conta<5l with one another, ic 
 ought to be immediately effedled in the 
 manner we (hall diredl in another chapter 
 when treating of Gaftroraphy. This at 
 leafl affords a chance of the ends of the 
 gut being brought to reunite ; and if un- 
 Y 2 fortunately 
 
340 OfHernict* Chap.V. 
 
 fortunately that event fhould not take 
 place, as the gut ought here alfo to be con- 
 nedled to the parts contiguous to the wound 
 in the abdomen, a pafTage fo^ the feces will 
 ftill be fecured by the groin. 
 
 Although in cafes of hernia, attended 
 with a mortification of the inteftines, many 
 have recovered by the method we have re- 
 commended whootherwife mufl have died; 
 yet it will be readily fuppofed, that the rifk 
 attending patients in fuch a (late mud be 
 very great ; But although a fmall propor- 
 tion only of fuch as are unfortunately in 
 this fituation fhould recover, yet ftill no 
 praditioner would be excufable for omit- 
 ting thofe means which afford the greatefl 
 probable chance of a recovery. A patient 
 of my own is now living, and in good 
 health, voiding his feces by the anus, who 
 loft at leaft one foot of the inteftinal canal 
 by mortification in a cafe of crural hernia; 
 and we are told by different authors, of 
 fimilar recoveries equally remarkable. 
 
 It is to the moderns chiefly, we muft re- 
 mark, that this very material improvement 
 
 in 
 
Scd. II. Of Herman 341 
 
 in the treatment of hernia is to be attri- 
 buted. It is even recorded of Rau, who li- 
 ved in a very late period, that on opening 
 a hernial fac, where a gangrenous ftate of 
 the parts was detecfled, as the cafe was 
 confidered as defperate, he laid down his 
 knife and proceeded no farther in the ope- 
 ration. This patient, who died next day, 
 would in modern pradlice have had at leaffc 
 fome chance for life. 
 
 When it is therefore difcovered, that part 
 of the contents of the fac are mortified, all 
 fuch portions as are to be removed ought 
 to be cut off; and the remaining found in- 
 teftine being retained till properly fecured 
 by a ligature, the opening in the external 
 oblique mufcle may then be dilated with 
 fafety : Whereas, if it fliould be enlarged 
 before the difeafed part of the gut is taken 
 away, the gangrenous portion might very 
 probably flip up together with the found ; 
 but by the precaution nov>r recommended, 
 every rifk of this nature is prevented. 
 
 The parts forming a hernia being all 
 
 completely replaced, when the fac in which 
 
 Y3 they 
 
342 Of Herni£, Chap. V, 
 
 they were contained is found thick, hard, 
 and much enlarged, as in fuch a ftate no 
 good fuppuration can take place, and as its 
 prefervation cannot be in any degree ufeful, 
 fuch parts of it as can be cut away with 
 propriety ought to be removed : All the 
 lateral and fore-parts of the fac may be cut 
 oft with fafety ; but as it is commonly firm- 
 ly connecfled with the fpermatic velfels be- 
 hind, this part of it ought not tp be touched. 
 
 The operation being now finiflied, by 
 the protruded parts being replaced, and 
 thofe intended to be removed being cut off 
 in the manner direded, the remaining fore 
 muft be dreifed as lightly as pofTible with 
 charpeeof thefofteftkind; andthebeft ban- 
 dage for retaining thedrefhngs, is the ufual 
 fufpenforybagproperlyftufFedwithfoftlint. 
 
 The pat:ent on being carried to bed 
 {hould be fo placed as to have his loins 
 fomewhat elevated above the reft of his 
 body, and fliould in that fituation be im- 
 mediately laid to reft: Opiates are here par- 
 ticularly ufeful : To prevent, or at leaft to 
 jnoderate, the fever which commonly fuc- 
 
 ceeds^ 
 
Se(5l. II. Of Hernics, 343 
 
 ceeds, the patient fhould be kept cool ; in 
 plethoric habits, blood letting fhould be 
 prefcribed, together with a rigid low diet; 
 and laftly, a frequent ufe of gentle laxa- 
 tives, fo as to keep the belly moderately 
 open, is particularly proper. 
 
 When however the conftitution has been 
 previoufly much reduced, either bv long 
 ficknelsor any other caufe, inftead of blood- 
 lettmg and a low diet, a noanlhing regi- 
 men fhould be prefcribed ; for if a patient 
 in fuch circumftances be not properly fup- 
 ported, he will noc fo readily recover trom 
 the efFe(fls of the diforder : And it is pro- 
 per to remark, that in ordinary pardlice, the 
 indifcriminate ufe of blood-letting, and 
 an abflemious regimen, in every cafe of 
 hernia, appears to be too rigidly adhered 
 to ; for althous:h this pradice proves al- 
 ways more effecflual than any other means 
 in every cafe of rupture attended with in- 
 flammation, yet daily experience convinces 
 us of its being highly pernicious where the 
 fyftem has been already much reduced by 
 evacuations, and where no inflammatory 
 fymptoms take place. 
 
 Y4 Th? 
 
344 Of Hernia, Chap. V, 
 
 The fore being regularly drefied as often 
 as it appears neceffary in the fame eafy 
 manner as at firft, and the fame degree o£ 
 caution being continued both with refpedl 
 to diet and other circumftances, if the pa* 
 tient furvives the firft three or four days he 
 willin general recover : And as foon as the 
 fore is firmly cicatrifed, a trufs ought to 
 be properly fitted to the parts, and fhould 
 never in any future period of life be laid 
 afide. 
 
 By many it has been recommended, and 
 it is ftill a very common practice, to flitch 
 up the wound with two or three futures ; but 
 as no real advantage can be obtained from 
 this, and as it has been on fome occafions 
 productive of mifchief, it ought not to be 
 attempted. No perfon will probably fay, 
 that fuch ligatures ought to be carried fo 
 deep as the tendon of the oblique mufcle ; 
 and if they are only made to pafs through 
 the external teguments, they can have no 
 effect in preventing a protrufion of intef- 
 tines : On the contrary, it does now and 
 then happen, during the cure of the wound 
 after this operation, that fmall portions of 
 
 gut 
 
Se6t. II. Of Hermes, 345 
 
 gut pafs out at the opening in the tendon, 
 which are always readily feen and eafily 
 reduced when the external parts have not 
 been drawn together ; but on the fkin be- 
 ing by ligatures made to cover the greateft 
 part of the wound, 1 have known it more 
 than once happen, that portions of inte- 
 (lines have palTed out at the opening in the 
 tendon, and remam protruded for a confi- 
 derable time without being noticed; fo that 
 the practice ought not to be encouraged. 
 
 After laying the fac bare, it was fome 
 time ago recommended by Mr Petit and 
 other French praditioners, to endeavour to 
 reduce the protruded inteftine without di- 
 viding the fac. One great advantage ex^ 
 peeled from this, was, the prevention of 
 thofebad confequences which are fuppofed 
 will mod likely enfue from the external air 
 finding accefs to the contents of the abdo- 
 men. 
 
 It ought to be remembered, however, 
 that unlefs the hernial fac is laid open, we 
 cannot poffibly know in what (late the pro- 
 tjruded bowels are ; fo that parts might be 
 
 returned 
 
34^ OfHernice, Chap.V, 
 
 returned into the abdomen in fuch a ftate 
 of difeale as would add greatly to the pa- 
 tient's rifk. Not only the inteftines are 
 liable to mortification, but colledions are 
 apt to occur in the hernial fac, of a very 
 fetid putrid ferum, which, on being pufhed 
 into the abdomen, might be produdive of 
 much mifchief. And befides, it has fome- 
 times happened, that, on laying open a 
 hernial fac,, the caufe of ftrangulation has 
 been deteded, either in the entrance to the 
 fac itfelf, or among the parts protruded 
 along with it: For although, in a great pro- 
 portion of all the inftances of hernia that 
 occur, a flridlure of the pafTage in the ex- 
 ternal oblique mufcle is to be confidered 
 as the caufe of all the bad fymptoms, yet 
 now and then inftances of the contrary 
 are obferved ; one of which I met with 
 fome years ago, and I have heard of others 
 of the fame kind. — In a cafe of fcrotal her- 
 nia of long (landing, fymptoms of ftran- 
 gulation at laft fupervened ; and on laying 
 open the fac, the appendix vermiformis 
 was found fo tightly twifted round a por^ 
 
 tioa 
 
Se^l II. Of Hernia, 347 
 
 tion of gut, as left no reafon to doubt of 
 that circumftance alone having been the 
 canfe of all the mifchief. If the parts had 
 here been returned into the abdomen with- 
 out dividing the fac, no advantage what- 
 ever would have occurred from the ope- 
 ration ; and, after death, the pra(flitioner 
 would have had the mortification to find, 
 that, in all probabiUty, the patient's life 
 might have beeenfaved, if this very necef- 
 fary meafure had not been omitted. 
 
 Inftances of the protruded parts being 
 returned into the abdomen without open- 
 ing the fac, are enumerated by different 
 French authors ; and in fome of thefe 
 which ended fatally, it was found on dif- 
 fe(5lion, that flrangulation of the gut had 
 been occafioned by ftridlure formed by 
 the parts contained within the fac, and 
 not by the tendon of the external oblique 
 mufcles. 
 
 Difafters of a nature fimilar to thefe we 
 have mentioned, having on different occa- 
 fions occurred to Mr Petit and others who 
 |i^d adopted the pradiee of returning the 
 
 parts 
 
34^ ^f ^^^"'^<^- Chap. V, 
 
 parts contained in the fac without divid- 
 ing the fac itfelf, it has now accordingly 
 been very generally laid afide. Even Mr 
 Petit himfelf was at laft fo convinced of 
 the inconveniences refulting from it, that 
 he is faid to have joined keenly with thofe 
 who had oppoled it from the time of its 
 being firft introduced. 
 
 By fome authors again, it is advifed, to 
 reduce not only the protruded bowels, but 
 even the hernial fac itfelf, without opening 
 it ; whilft, by others, it is alleged, that the 
 fac can never be reduced. Mr Louis, in the 
 paper we have already quoted, is clearly of 
 this lad opinion, as Mr Pott alfo is. But 
 w^e have the teftimony of different authors 
 of credit, and particularly of Mr Le Dran, 
 to the contrary ; and I have myfelf met 
 with one inftance of this, where the ap- 
 pearances were fo unequivocal as to leave 
 no doubt with me refpedling it. 
 
 In cafes of hernia where the parts have 
 been long and repeatedly down, fuch firm 
 adhefions are ufually formed between the 
 fac and the contiguous parts, as to reduce 
 
 them 
 
Sea. II. Of Hernia, 349 
 
 them apparently into one infeparable mafs ; 
 fo that, in fuch circumftances, redudion of 
 the fac becomes altogether impra(flicable. 
 But although this is perhaps in every in- 
 ftance found to be the cafe in ruptures of 
 long continuance, we are by no means war- 
 ranted in fuppofing that it is fo in eyery 
 cafe of recent hernia. We know that the 
 adhefion of one part of the body to another, 
 cannot any where be inftantaneoufly pro- 
 duced. Even where recent divifion has ta- 
 ken place, and when the divided parts are 
 kept in clofe contadl, the fpace of feveral 
 days is commonly required to effedl a firm 
 reunion. Now in the cafe of a portion of 
 membrane being forced into a naturalopen- 
 ing, where the parts are neither rendered 
 raw by art, nor are as yet affected with in- 
 flammation, a ftill longer period we may 
 fuppofe will be neceffary for this effecl; 
 and in fad, altho' I fuppofe there is fcarce 
 an inftance of a hernial fac of long dura- 
 tion being reduced, yec there are fundry 
 indifputable fads which fhow, that in re- 
 cent ruptures the facmay be returned. The 
 
350 Of Hernia, Chap. V^ 
 
 one above alluded to, which occurred in an 
 operation at which I was prefent feveral 
 years ago, had been down five or fix days, 
 and formed a tumor in the groin of the fize 
 of an ^^% : The fac did not in any point 
 feem to adhere ; the operator therefore 
 found no difficulty in reducing it; and on 
 difTedlion after death, which happened in 
 about two days from the operation, the paf- 
 fage through the external oblique mulcle 
 was found dilated, but no exiftence of a fac 
 could be traced into it. It is not, however, 
 my own opinion, that this is a matter of 
 much importance in practice, I mean the 
 pra(5licability of reducing the hernial fac or 
 not ; for, the various reafons we have already 
 given, againfl: the propriety of returning 
 the contents of a fac without opening it, 
 occur with equal force againft the propofed 
 pra(flice of returning the fac itfelf unopen- 
 ed. But as there is a poflibility of future 
 experience deriving fome advantage from 
 this circumftance,itiscertainly righttohave 
 the fad as clearly eftablifhed as poffible. 
 Hitherto we have been fuppofing the 
 1 dif-» 
 
Se(fl. 11. Of HernU. 351 
 
 diforder to exift in a male fubjecl only ; 
 but as the fame openings in the external 
 oblique raulble are met with in females, 
 fo they are alfo liable to the fpecies of rup- 
 ture we have juft been defcribing. 
 
 In males, however, the bubonocele is ob- 
 fcrvedto occur more frequently than in wo- 
 men, and as in them too the cellular mem- 
 brane furrounding the fpermatic veflels is 
 very lax and dilatable, fo hernial fwellings 
 of this kind are commonly much larger in 
 men than in women. But inftances do 
 now and then occur of fuch tumors even 
 in women becoming very large ; in fuch 
 cafes, the protruded parts fall down to the 
 very bottom almoft of the labia pudendi. 
 
 As the openings in the external oblique 
 mufcles of females are exceedingly fimilar 
 to thofe in male fubjedls, fo the treatment 
 of this fpecies of hernia is in them very 
 fimilar to what is found to anfwer in men. 
 In cafes of flrangulated gut, when glyfters, 
 blood-letting, and the other remedies for- 
 merly enumerated, happen to fail, the fame 
 operation of laying open the hernial fac, 
 
 and 
 
 \ 
 
352 Of Hernia. Chap.V, 
 
 and of enlarging the opening in the ten- 
 don of the oblique mufcle, is here equally 
 proper as in the other fex. 
 
 With modefl: women, diforders of this 
 kind often take place without the pradi* 
 tioner in attendance being made acquaint- 
 ed with them ; whenever therefore fuch 
 fymptoms of colic occur as give reafon to 
 fufpetft the exiftence of hernia, a particular 
 examination ought always to be made, in 
 order if poflible to detecfk the caufe of the 
 mifchief, from the removal of which a 
 cure can alone be expeded. 
 
 SECTION III. 
 
 Of the Hernial Congenita* 
 
 "D Y attending to the anatomical defcrip- 
 tion given in the firfl fecElion, of the 
 parts chiefly concerned in cafes of hernia, 
 it muft evidently appear, that in the ordi- 
 nary fpecies of fcrotal hernia, the parts pro- 
 truded from the abdomen muft of neceP- 
 fity be contained in a bag or fac perfedly 
 diftincl from the tefticle; which in that 
 3 kind 
 
Sc6l. III. Of Hernia, 2) SI 
 
 kind of rupture is always found in itsxifual 
 fituation in the ferotum, furrounded by its 
 own proper membrane the tunica vagina- 
 lis, and not in conta<fl with any other pare 
 whatever. 
 
 We then made it appear_too, that if in 
 early infancy a portion of gut fliould flip 
 down by the fame paffage with the teflicle, 
 that the parts fo protruded muft be in im- 
 mediate contadl with the teflis, and mud 
 thus be furrounded with the tunica vagi- 
 nalis; fo that in this fpeeies of rupture, 
 very properly by Haller termed Hernia 
 Congenita, the tunica vaginalis teftis forms 
 the hernial fae. 
 
 The difcovery of this fpeeies of hernia, 
 which was refer ved for modern times, en- 
 ables us to account for anumber of cafes 
 recorded in books of furgery, of the con- 
 tents of ruptures having been found in the 
 fame bag with the tellicle: A eircumftance 
 which, till this difcovery, was always con- 
 fidered as a clear proof of the peritoneum 
 being frequently ruptured in thofe difor- 
 =ders; as there was not otherwife a poffi- 
 Vol. I, Z bility 
 
35"4 ^f Herm(e, Chap. V. 
 
 bility of accounting for the phenomenon. 
 But we now know, that the perltonceum in 
 thefe cafes of hernia is never ruptured; and 
 that the parts forming a hernial tumor 
 being found in conta(fl with the tefticle, 
 is a circumftance eafily ex;^lained from our 
 more accurate anatomical knowledge of 
 thofe parts. 
 
 In the treatment of ruptures of the con- 
 genital kind, little difference occurs from 
 the management of the bubonocele in its 
 more ordinary form. When the parts can 
 be replaced without any operation, it ought 
 always to be done, a trufs being at the fame 
 time recommended as a preventative of 
 future defcents ; and when fymptoms of 
 ftrangulation take place, which cannot be 
 other wife removed than by the operation, 
 it here becomes equally neceflary as in any 
 other fpecies of rupture. 
 
 When from the circumftance of the 
 parts having been protruded in early in- 
 fancy, and from their hatting at times con- 
 tinued to fall into the fcrotum from that 
 period' downwards, there is reafon to fuf- 
 
 ped 
 
Seel. III. Of Hernia, 355 
 
 pecfb that the hernia to be operated upon is 
 of the congenital kind, thefurgeon in fuch 
 a cafe, in laying open the contents of the 
 tumor, muft proceed with ftill more cau- 
 tion than in cafes of ordinary rupture; for 
 the tunica vaginalis which here forms the 
 fac, is commonly much thinner than the 
 ufual fac of hernix. On the parts being 
 returned, more attention is neceiTary too 
 in drefling the wound than in other cafes of 
 hernia ; for the tefticle being here laid bare 
 by its vaginal coat being cut open, if it is 
 not treated with much delicacy it will very 
 probably inflame, and may thereby be pro- 
 duiflive of much diftrefs. The teftis there- 
 fore ought to be immediately enveloped 
 with its own proper covering, the loofe tu- 
 nica vaginalis; and at every drefling, care 
 ihould be taken to prevent as effectually as 
 poflible every accefs to the external air. 
 
 In other refpecfts the management of the 
 hernia congenita is perfedlly limilar to that 
 of any other rupture. 
 
 Z 2 . SEC- 
 
35^ OfHefni^. Chap. V. 
 
 S E C T I O N IV. 
 
 Of the Crural or Femoral Heryiia. 
 
 T^HE feat of this fpecies of hernia, aa 
 we have elfewhere remarked, is on 
 the upper and anterior part of the thigh ; 
 the protruded parts pafTmg aut at the fame 
 opening through which the large blood- 
 vefFels of the thigh are tranfmitted from 
 the abdomen. 
 
 In the defcription given in a former {to.^ 
 tion, of the external oblique mufcles of the 
 abdomen, the under tdi%t of thefe mufcles, 
 it was remarked, by doubling backwards, 
 forms a kind of ligament, which extends 
 in an obHque diredlion from the fpine of 
 the ileum near to the fymphifis pubis. It 
 is this under-border of thefe mufcles which 
 is commonly known by the name of Pou- 
 part's or Fallopius's ligament. 
 
 Excepting ac its two extremities where 
 this ligament is attached to the pubes and 
 ileum, it is not in any other part con- 
 nected with bone. By the particular fhape 
 o-f the^*ilenm at this part, a kind of arch is 
 
 formed 
 
Scd. IV. Of Hernia. 357 
 
 formed by the ligament paffingover a hol- 
 low in that bone through which the large 
 artery and veins of the thigh find a paf- 
 fage^ the reft of the cavity being filled up 
 with cellular fubftance, glands, and fat ; 
 and all thefe parts again are covered and 
 tied down by a firm tendinous aponeurofis 
 of the fafcia lata of the thigh. 
 
 It is under the tendon or ligament juft 
 now defcribed, that the parts compofing a 
 crural hernia defcend. On fome occafions 
 they pafs immediately over the femoral ar- 
 tery and vein ; on others, they are found 
 on the outfide of thefe veffels ; but more 
 frequently they lie on the infide, between 
 them and the os pubis. 
 
 As the protrufion of any of the abdo- 
 minal contents produces in this fituation 
 nearly the fame fet of fymptoms as occur 
 in cafes of inguinal hernia, the method of 
 treatment recommended in -that fpecies of 
 the difeafe is alfo applicable here. 
 
 When, therefore, in the femoral hernia, 
 
 fymptoms of ftrangulation occur, we muil 
 
 put all the remedies in pfadice already 
 
 Z 3 advifed 
 
358 OJ Hernia » Chap. V. 
 
 advifed for the inguinal rupture : Only 
 here, in attempting to reduce the parts by 
 the hand, the preiTure fhould be made di- 
 redlly iipwards, inftead of obliquely out- 
 wards, as we dh-ecled in the other ; and 
 when thefe means are unfortunately found 
 to fail, the operation itfelf mufl then be 
 employed. 
 
 A free external incilion was inculcated 
 in cafes of inguinal hernia; and it is here 
 equally neceffary, or even more fo, from the 
 parts concerned being more deeply feated 
 than in the other. By too much timidity 
 in making the external incifion, the ope- 
 rator is frequently much incommoded in 
 all the fubfequent fleps of the operation. 
 The external cut (liould extend at leaft from 
 an inch above the upper end of the tumor 
 to the fame fpace below the mod depend- 
 ing part of it. 
 
 The membrana adipofa, tendinous ex- 
 panfion of the fafcia lata, and hernial fac, 
 being all cautioufly divided, if the pro- 
 truded parts are found in a iituation pro- 
 per for reauclion, we fnould immediately 
 
 attempt 
 
Sea. IV. OfHernU, 359 
 
 attempt to replace them ; and as the fpac.e 
 below the ligament through which they 
 have pafled is coniiderable, this may fre- 
 quently be done without dividing the liga- 
 ment, merely by preiTure properly applied 
 with the hand, while the patient's body is 
 placed in the pofture we have already di- 
 recfledin the bubonocele as being beft fuit- 
 ed for favouring a return of the bowels. 
 
 When in this manner the -contents of the 
 tumor can be reduced without the necef- 
 fity of dividing the ligament, the patient 
 is thereby faved from a great deal of ha- 
 zard, as from the particular fituation of 
 the fpermatic veflels and epigaftric artery 
 with refpedl to this ligament, any cue 
 made into the fubftance of the latter, runs 
 a very great rifk of dividing one or other 
 of them. 
 
 The fpermatic veffels as they go along 
 to pafs out at the opening in the external 
 oblique miifcie, run nearly upon the very 
 edge or border of Poupart's ligament al- 
 mofl through its v/hole length, fo that I 
 coniider it as impoffible to make a free 
 Z 4 divi-- 
 
2^o Of Hernia. • Chap. V» 
 
 divifion of the ligament without cutting- 
 them acrofs. 
 
 We have been advifed indeed by fome, 
 in order to avoid v^ounding the fpermatic 
 vefTels, which they acknowledge would cer- 
 tainly happen if the incifion fhould be car- 
 ried diredly upwards, to cut in an oblique 
 diredion outwards. In this method, they 
 allow, that the epigaftric artery, from the 
 courfe it ufually takes, may very probably 
 be divided : But the rifk attending the di- 
 vifion of that artery they do not confider 
 as of much importance; and if the dif- 
 charge of blood occafioned by any wound 
 that may be made in it fliould happen to be 
 confiderable, they fpcak of it .as a very eafy 
 matter to take it up by a needle and liga- 
 ture, and needles of various fliapes have 
 been invented for this purpofe. Even in 
 emaciated people, however, it is a matter 
 of much difficulty to reach the epigaftric 
 artery, and in corpulent patients it will be 
 found altogether impoilible to furround it 
 with a ligature ; fo that the younger part 
 of the profelTion oL^ght to be very cautious 
 
Sea. IV. ♦ of Hernice 361 
 
 in receiving the diredlions ufually given on 
 this fubjed. On reading the remarks of the 
 late Mr Sharpe upon this point*, to fecure 
 the epigaflric artery by means of a ligature, 
 one would expedt to be the eafieft of all 
 operations; but the difficulty which in re- 
 ality attends it, is fuch as muft convince 
 every one who has tried it, that Mr Sharpe 
 himfelf had never put it in pradice. 
 
 But even although this accident of 
 wounding the epigaflric artery could be 
 guarded againft in the moft eafy and effec- 
 tual manner, yet 1 will venture to fay, 
 when a femoral hernia is of any coniider- 
 able fize, the diflention of the ligament 
 thereby produced muft bring the fpermatic 
 veffels fo nearly on a line with the under 
 border of the ligament, as to render it al- 
 together impoffible to divide the one with- 
 out the-other ; and whoever will examine 
 thefe parts in the flate we have now de- 
 fcribed, will fee that this cannot be avoided, 
 whether the . incifion be carried direcflly 
 
 upwards, 
 
 • Critical Inquiry into the prefent Hate of Surgery. 
 
362 OfHernice* Chap. V, 
 
 upwards, or even obliquely outwards or 
 inwards. 
 
 Some authors, from being fenfible of the 
 danger attending this part of the operation, 
 have propofed merely to dilate the pafTage, 
 inftead of dividing the ligament ; and Mr 
 Arnaud, a French writer on this fubjedl, 
 delineates a curved levator for the purpofe 
 of fupporting the ligament till the pro- 
 truded parts are reduced : but as we are to 
 fuppofe in every cafe of ftrangulated her- 
 nia, that the paflage through which the 
 parts have fallen down is already dil-ated 
 to nearly its utinoft poflible extent, in fuch 
 a Situation to attempt a farther dilatation 
 without the afTiftance of the knife, would" 
 feldom, it is probable, be produ6live of 
 any advantage. 
 
 A confiderable time ago it occurred to 
 me, that in this part of the operation fome 
 affiftance might be derived from perform- 
 ing it in the following manner ; and ha- 
 ving fince had occalion to make trial cf it 
 in one cafe where it anfwered mod effec- 
 tually, I can now therefore recommend it 
 
 with 
 
Sea. IV. O/Hernw, 363 
 
 with fome certainty. Inftead of dividing 
 the ligament in the ordinary way, I only 
 made an incifion into part of its thicknefs: 
 In order to protect the parts below, I firft 
 infinuated the fore-iinger of my left-hand 
 between the gut and the ligament ; and 
 then with a common fcalpel made a cut of 
 about an incli in length, beginning above 
 and proceeding to the under border of the 
 ligament. 
 
 The firfl fcratch with the fcalpel was 
 very flight ; but by repeated touches, it 
 Was made to penetrate almoft through the 
 whole thicknefs of the ligament, till at lad a 
 very thin lamella only of it remained: The 
 finger being now withdrawn, the protru- 
 ded parts were returned with great eafe, 
 the ligament at its weakened part yielding 
 gradually as the neceffary prefTure was ap- 
 plied for the redudion of the inteflines. 
 
 As in this manner the opening may be 
 enlarged to any necefTary extent, and as 
 the fpermatic veiTels and epigaflric artery 
 are thus effecflually avoided, the operation 
 for this fpecies of hernia may not only be 
 
 done 
 
364 Of Hernia. Chap.V. 
 
 done with equal certainty, but with the 
 fame degree of fafety, as for any other 
 kind of rupture. For, by not penetrating 
 with the fcalpel through the whole thick- 
 nefs of the ligament under which thefe 
 blood-veffels lie, they are thereby kept 
 free from all kind of danger during this 
 part of the operation ; and, the prefTure to 
 be afterwards ufed for the redudlion of 
 the protruded parts, if done in an eafy 
 gradual manner, as it ought always to be, 
 can never injure them materially; as 
 blood- vefTels of the fize and ftrength of 
 which thefe are, eafily admit of a degree 
 of extenfion much more confiderable than 
 can be here required. 
 
 The femoral hernia being in other re- 
 fpedls perfeAly fimilar to the inguinal, 
 and the mode of treatment applicable to 
 the one, being in every other circumftance 
 equally fo to the other, it is not neceflary 
 to fay any thing farther here concerning 
 it : Only we may remark with refpedl to 
 bandages for retaining the drefhngs, both 
 in this and every other fpecies of hernia, 
 
 excepc 
 
Ssdl. IV. OfHernite, 365 
 
 except in the bubonocele, as lad de- 
 feribed, in which the ordinary fufpenfory 
 bandage of the fcrotum anfwers the pur- 
 pofe in a- very eafy efFedual manner, that 
 in no other fituation can a bandage be ap- 
 plied, without being produflive of much 
 inconvenience. For indance, the Spica, as it 
 is termed, which after the operation of the 
 crural hernia, ufed always to be employed, 
 can never be applied but with much dif- 
 ficulty ; nor does it anfwer the purpofe 
 properly : Inftead of this or any other 
 bandage, a piece of thin leather fpread 
 with any plafter moderately adhelive, be- 
 ing applied over the dreflings, retains 
 them more efFedually, and with much 
 more eafe. 
 
 We have elfewhere remarked, that from 
 the particular conformation of the parts 
 concerned in this difeafe, which is found 
 to take place in females, that women are 
 more liable to it than men. In them 
 the fame means of relief, and the fame 
 mode of operating, ought to be em- 
 3 ployed 
 
2^66 Of Hernia, Chap. V. 
 
 ployed as we have already advifed for 
 male fubjedls. For, as the fame rij[k oc- 
 curs here of wounding the eplgaftric ar- 
 tery, the fame precautions are neceflary for 
 avoiding it; and by attending to the direc- 
 tions we have given upon this point, this 
 may be always done with certainty. 
 
 SECTION V. 
 
 Of the Exomphaks, or Umbilical Rupture. 
 
 Tn this fpecies of hernia, the parts pro- 
 truded from the abdomen pafs out at 
 the umbilicus ; and the contents of the 
 hernial fac are here, as in every other kind 
 of rupture, exceedingly various. On fome 
 occaGons they confift of inteftines only ; 
 fometimes of omentum only ; and fre- 
 quently of both. At other times, again^ 
 part of the ftomach, the liver, and even 
 the fpleen, have been found in the fac of 
 an umbilical rupture. 
 
 As all the parts we have now men- 
 tioned, are, while in the abdomen, con- 
 tained in the peritoneum, the hernial fac, 
 
 it 
 
Sea.V. Of Hernia. 367 
 
 it is evident, mufl be here formed as well 
 as in other ruptures, by that membrane 
 being carried along with fuch parts as are 
 protruded. Accordingly, in every recent 
 inftance of umbilical hernia, this fac is in 
 general very evident ; but when the tu- 
 mor has become confiderable in fize, by 
 a long continuance, and the great weight 
 of its contents, the fac, by the preffure thus 
 produced, becomes fo connedled with the 
 neighbouring parts, that by many it has 
 been doubted whether this fpecies of her- 
 nia has a fac or not. In ruptures of this 
 kind the fwellings fometimes increafe to 
 fuch a degree, as actually to burft the 
 furrounding parts ; not only the fac, and 
 cellular fubftance, but even the fkin it- 
 felf 
 
 This diforder occurs mod frequently in 
 infancy, foon after birth ; and corpulent 
 people are more liable to it than thofe of 
 a contrary habit, from this evident reafon, 
 that in the former, by the great bulk of 
 contained parts, the furrounding mufcles 
 are kept conftantly diilended, and the 
 3 .open- 
 
i68 Of Hmila. Chap. V. 
 
 opening at the umbilicus through which 
 the parts are protruded, Is- thereby made 
 more pervious : For the fame reafon too, 
 women in the laft months of pregnancy 
 are particularly liable to umbilical rup- 
 tures. 
 
 If the diforder is attended to in due time, 
 a bandage properly fitted to the parts will 
 commonly efFedl a cure ; and, in fuch fwel- 
 lings as occur in pregnancy, a removal of 
 the diforder, is, in general, a certain confe- 
 quence of delivery. But even in cafes of 
 umbilical hernia in pregnant women, by 
 employing a bandage on the firft appear- 
 ance of the difeafe, and by perfevering iii 
 the ufe of it for a proper length of time> 
 although a cure may not be obtained till 
 delivery, the diforder will at leaft be pre- 
 vented from receiving any farther increafe. 
 Both in male and female patients, due at- 
 tention to the ufe of a trufs is abfolutely 
 necelFary in every cafe of hernia ; but as 
 in this fpecles of the difeafe the fwelling 
 and different fymptoms are always greatly 
 aggravated by pregnancy, women in that 
 
 ftate 
 
Sea.V. OfBerma, 369 
 
 Hate ought to be particularly attentive to 
 the fmallefl: appearance of every fwelling 
 of this nature. 
 
 Although in fomeinftances of umbilical 
 ruptures, different portions of the alimen- 
 tary canal are found to be protruded ; yet 
 by experience vv^e know, that the omentum, 
 alone is much more frequently protruded 
 than any of the other vifcera : And hence 
 umbilical hernias in general, are not pro- 
 dudlive of fuch bad fymptoms as ufually 
 occur in the other kinds of rupture. 
 
 It happens, however, as we have already 
 obferved, that in fome cafes a portion of 
 gut alone is pulhed out, by which the ufual 
 fymptoms of a flrangulated hernia are apt 
 to be induced. In which event, when the 
 means ufually employed for returning the 
 gut into the abdomen do not fucceed, as a 
 Itridlure of the pafFage through which the 
 gut has fallen, is to be confidered as the 
 caufe of the.diforder; fo a cure, it is evi- 
 dent, muft depend entirely on a thorough 
 removal of that flridure. In performing 
 this operation, a free external inciiion along 
 Vol. I. A a the 
 
n^ Of Hernia ^ Chap.V. 
 
 the courfe of the tumor, is the firft ftep to 
 be taken; and on laying the protruded 
 parts bare by a cautious divifion of the fac^ 
 if they are found in a ftace proper to be 
 returned, and if that cannot be effedled 
 without making an enlargement of the 
 paffage into the abdomen, this may be done 
 with great fafety by introducing the finger^ 
 and enlarging the opening as far as is ne* 
 cefTary with the blunt-pointed biftoury. 
 This incifion, we may remark, may be 
 made with almoft equal fafety in any di- 
 re(flion ; but left the ligament formed by 
 the umbilical vefFels Ihould be wounded, 
 which, however, would not probably occa- 
 fion much injury, yet if any perfon is ap- 
 prehenfive of danger from that circum- 
 ilance, it may be always avoided by ma- 
 king the incifion on the left fide of the 
 umbilicus, and carrying it a little oblique- 
 ly upwards and outwards. 
 
 When, again, the prolapfed parts, on 
 being laid open, are found to be fo far 
 difeafed ais to render their redu(5lion im- 
 proper, the direcflions formerly given for 
 
 the 
 
Se<fl. V, Of Hernl^^ 37 1 
 
 the treatment of fimllar occurrences in other 
 cafes of hernia, apply with equal propriety 
 here, fo that they need not now be repeated. 
 
 By Albucafis, Guido, Aquapendens, and 
 Other authors, it has been propofed, with a 
 view to obtain a radical cure without ha- 
 ving recourfe to the operation, to lift up 
 the Ikin covering the tumor, with the fin- 
 ger and thumb, fo as to feparate it from 
 tHe gut underneath ; when a hgature is 
 ordered to be applied round the parts fo 
 held up, and to be made of fuch a tight- 
 nefs as to induce a mortification of all the 
 parts that lie anterior to it. 
 
 In other inftances again, when the form 
 of the fwelling did not admit of this, the 
 fame precaution being taken as we have di- 
 rected above for avoiding the gut, a needle 
 containing a double ligature was introduced 
 at the bafis of the tumor, near to its centre, 
 and the ligatures were afterwards tied one 
 above and the other below, of fuch a de- 
 gree of tightnefs as to induce the wiihed 
 for effecfl. 
 
 But as the practice thus recommended 
 A a 2 was 
 
372 Of Hernia, Chap. V. 
 
 was not adequate to the defigii propofed, 
 as it did not prevent a return of the dif- 
 order, and as the deftrudlion of fkin pro- 
 duced by it rendered every future defcent 
 more dangerous ; fo it is now, at leafl by 
 regular pra^flitioners, very univerfally ex- 
 ploded. 
 
 SECTION VI. 
 
 Of Ventral Hernia, 
 
 TN this fpecies of hernia the parts form- 
 ing the fwelling are protruded between 
 the interftices of the abdominal mufcles. 
 No part of the abdomen is altogether ex- 
 empted from the occurrence of fuch tu- 
 mors, but they are mod frequently obfer- 
 ''ved in fome of the parts mofl contiguous to 
 the linea alba; and when the ftomach alone 
 happens to form the tumor, the fwelling 
 is fituated jufl under, or immediately to 
 one fide of the xiphoid cartilage. 
 
 The treatment of this kind of rupture 
 corrcfponds exadly with thatof exompha- 
 los. When the parts are reducible by the 
 
 hand 
 
Sea. VII. OfEernia. ^^^ 
 
 hand merely, a cure may be frequently 
 obtained by the conftant ufe of a trufs; 
 and, again, when fymptoms of flrangula- 
 tion occur, which cannot be otherwife re- 
 moved than by an incifion through the 
 ilridure, this mud be done in the man- 
 ner direcSted in the lad Sec'lion, fo as to 
 admit of the parts being replaced. The 
 after-treatment of the parts concerned in 
 the operation, is the fame here as in other 
 kinds of rupture. 
 
 SECTION VII. 
 
 Of the Hernia of the foramen Ovale, 
 
 TN this variety of rupture, the vifcera 
 protrude through the foramen ovale of 
 the pubis ^and ifchium. It is not by any 
 means a frequent diforder ; but, as it does 
 fometimes occur, it is neceiTary here to 
 defcribe it. 
 
 The fymptoms in this kind of hernia 
 
 being very fimilar to thofe produced by 
 
 the ftrangulation of inteftines in other 
 
 parts, it is not neceffary to enumerate 
 
 A a q[ them : 
 
-574 Of Herntip, Chap. V. 
 
 them : Only it is proper to remark, that in 
 this rupture the tumor is in men formed 
 near to the upper part of the perinseum ; 
 and in \Tomen, near to the under-part of 
 one of the labia pudendi. In both fexes it 
 lies upon the obturator externus, between 
 the pedlinsus mufcle and the firft head of 
 the triceps femorls. 
 
 The foramen ovale being partly filled 
 up by a membranous or ligamentous fub- 
 ftance, and in part by the obturatores 
 mufcles, it was commonly fuppofed that 
 this fpecies of hernia arofe from a relaxa- 
 tion of one or other of thefe ; but as an 
 opening is left in the foramen for the 
 tranfmiffion of different blood-veffels and 
 nerves, it is now known, that in this dif- 
 order the vifcera pafs out at that openings 
 by gliding down in the courfe of thefe 
 veflels. 
 
 The general mode of treatment as we 
 formerly recommended for other fpecies 
 of hernia, mufl be here attended to ; and 
 ■when the parts are reduced, a trufs pro- 
 perly ad?.pted to the parts, muf^ be trufled 
 
 to 
 
Sea. VIL OfHernug. 375 
 
 to far their retention. But as it will ibme- 
 cimes happen in this, as in every other cafe 
 of hernia, that redu6lion cannot be efFecfl- 
 ed by the hand alone, in that event the 
 operation of dilating the paflage through 
 which the inteftiiies proirude, is the only 
 refource. The tumor, however, that oc- 
 curs in this diforder, being in general fo 
 fmall as fcarcely to be noticed but by the 
 moft minute examination, unlefs a locai 
 pain, with the ufual fymptoms of a ftran- 
 gulated gut lead to its detedion, it is fei- 
 dom difcovered from its fize, till it is too 
 late to expe<3: much affiftance from art. 
 
 But whenever the operation becomes ne- 
 ceffary, as it mud always be when fymp- 
 toms of flrangulation are difcovered to 
 have arifen from a portion of gut being 
 protruded, and which cannot by any other 
 means be removed ; in fuch an event, af- 
 ter carefully laying the prolapfed parts 
 freely bare, if they cannot then be reduced 
 but by dilating the pafTage, and as death 
 mud be the certain confequence if that 
 ihould not be effecfled; it ought at all events 
 A a 4 XXI 
 
9yS Of Herma, Chap.V. 
 
 to be attempted : But as here it is almofl 
 impoffible to enlarge the opening by means 
 of any fharp inftrument, without dividing 
 feme of the blood-veflels which pafs out at 
 the foramen ; and" as fuch an occurrence, 
 from thefe veflels being of a confiderable 
 fize, would of itfelf, in all probability, end 
 in the patient's death, the depth and fitua- 
 tion of the parts rendering the application 
 pf a ligature impracticable; it is more ad- 
 vifable, by means of fuch a flat hook as is 
 reprefented in Plate IX. fig. 2. to dilate the 
 paiTage to a fufficient fize by gentle gra- 
 dual flretching. By infinuating the end 
 of the hook between the intefline and li- 
 gament, and pulling it gradually from 
 without inwards, a degree of dilatation 
 may be obtained fufhcient for the reduc- 
 tion of the gut, without incurring that ha- 
 zard which the divifion of the ligament 
 with the knife or any (harp inftrument 
 muft always occafion. 
 
 SEa^ 
 
Sea. VIII. Of Hernia. 3 77 
 
 SECTION VIII. 
 
 Of the Hernia Cyftica, or Hernia of the Urinary 
 Bladder. 
 
 TN this fpecies of rupture, the urinary 
 bladder is the organ protruded; and the 
 fituations in which it occurs, either in the 
 groin and fcrotum, through the opening 
 in the external obUque mufcle of the abdo- 
 men ; in the fore-part of the tnigh, under 
 Poupart's ligament; or in the perineum, 
 through fome of the mufcular interftices 
 of that part *. Inftances have occurred, 
 too, of the bladder being pufhed into the 
 vagina, fo as to form hernial tumors of no 
 inconfiderable degrees of magnitude. 
 
 As only a part of the bladder is covered 
 with the peritonaeum ; and as the bladder, 
 in order to get into the opening in the ex- 
 ternal oblique mufcle, or under the liga- 
 ment of Fallopius, mufl iniinuate itfelf 
 between that membrane and the abdo- 
 minal mufcles ; it is evident, that the 
 3 hernia 
 
 * An inftance of this is recorded in Vol. IV. of 
 ISIemoires de 1' Academic Royale de Chirurgie, by 
 Monf. Pipelet le Jeune, p. i8i. 
 
578 Of Hernia. Chap.V. 
 
 hernia cyflica cannot be covered with a fac, 
 as inteftinal ruptures ufually are. In the 
 perinsEum, again, that portion of the blad- 
 der moft liable to fall into it, is in no way 
 conneded with the peritonseum. On fome 
 occafions, this fpecies of rupture occurs by 
 itfelf, without any complication; and on 
 others it is found to be accompained with 
 inteftines and omentum, both in inguinal 
 and femoral herniae : When complicated 
 with a bubonocele, that portion of the blad- 
 der which is protruded lies between the 
 hernial fac and fpermatic cord ; that is, the 
 inteftinal hernia lies anterior to it. 
 
 The ufual fymptoms of this fpecies of 
 hernia are, A tumor, attended with fluc- 
 tuation, either in the groin, in the fore- 
 part of the thigh, or perinseum, which 
 generally fubfides when the patient voids 
 urine. When the fwelling is large, before 
 water can be made with freedom, it is 
 commonly neceflary to have recourfe to 
 preflare, at the fame time that the tu- 
 mor, when in the groin or thigh, is as 
 much elevated as poffible; but when the 
 
 fwelling 
 
fwelling is fmall, and efpecially when no 
 ftridture is as yet produced, the patient 
 generally makes water with great eafe, 
 and without any affiftance from external 
 preflure. 
 
 When a hernia of the bladder occurs 
 
 without any complication, it is common- 
 ly found to proceed from a fuppreffion of 
 urine. In the treatment, therefore, every 
 caufe of fuppreffion ought as far as pof- 
 iible to he guarded againft; and when no 
 adhefions take place, and if the protruded 
 portion of bladder can be reduced, a trufs 
 properly fitted to the part, fhould be wore 
 for a confiderable length of time: And, 
 again, when the parts cannot be reduced, 
 as long as no fymptoms occur to render 
 the operation neceffary, a fufpenfory bag, 
 fo fitted as eflPec^lually to fupport the pro- 
 lapfed parts, while at the fame time it does 
 not produce fevere prefTure, is the only 
 , probable means of relief. When, again, 
 a portion of bladder happens to protrude 
 into the vagina, after reducing the parts, 
 "^^hich is done by laying the patient on her 
 
 back 
 
jSo Of Hermes. Chap. V, 
 
 back with her loins fomewhat elevated, 
 and preffing with the fingers from the va- 
 gina, defcents in future may in general 
 be effeclually prevented by the ufe of the 
 preffary reprefented in Plate IX. fig. i . And 
 the fame means, we may remark, are em- 
 ployed with fuccefs in preventing a fall- 
 ing down of part of the inteftinal canal 
 into the vagina; a fpecies of rupture which 
 now and then occurs. 
 
 It may happen, however, that the pro- 
 lapfed parts, by being attacked with in- 
 flammation and pain in confequence of 
 flricture, may render the divifion of the 
 parts producing thefe fymptoms as ne- 
 cefTary in this as in any other cafe of her- 
 nia; in which event, the directions given 
 in the preceeding feclions for the treatment 
 of inteftinal hernias, will be equally appli- 
 cable here. — Only it muft be remembered, 
 that as in the hernia cyftica without any 
 complication, the protruded parts are not 
 covered with a fac; fo a ftill greater de- 
 gree of caution is neceffary in laying them 
 
 bare. 
 
Tlate ISl. 
 
 ^ca^J 
 
 c'^/Jr/Zchv^^^ 
 
 ^:f 
 
Sea. VIII. Of Hermes, 3gi 
 
 bare, than in the ordinary kinds of rup- 
 ture. 
 
 It fometimes happens, that ftones are 
 produced Un that portion of the bladder 
 which remains protruded ; in which event, 
 if it fhould ever become necefTary to cut 
 into them, if the bladder can be ealily re- 
 tained in its prolapfed flate till the wound 
 is healed, it ought always to be attempt- 
 ed, in order to prevent that extravafation 
 of urine internally which would otherwlfe 
 occur, and which in all probability would 
 do mifchief. The fame precaution, too, 
 becomes necelTary, if, either by accident 
 in the operation for the hernial cyftica, the 
 bladder fliould be cut into ; or if any part 
 of it has been found mortified, fo as to 
 render it improper to return it into its 
 ufual lituation *. 
 
 CHAP. 
 
 * The beft accounts to be obtained of the various 
 fpecies of hernia may be had in the works of Le Dran, 
 Heifter, and of Mauchart in a treatife Be Hernia Incar- 
 ceratj, ; in the different volumes of Memoires de I'Aca- 
 demie Royak de Chirurgie of Paris ; in the Medic?.! Ef- 
 
 favs 
 
382 Of the Hydrocele. Chap. VI. 
 
 CHAP. VI. 
 
 (y/^^ Hydrocele. 
 
 S E C T I O N I. 
 
 General Remarks on the Hydrocele, 
 
 E^ VERY tumor formed by a colledion 
 J of water, might, from the import of 
 the word, be with propriety denominated 
 3 a 
 
 fays of Edinburgh; In the Works of the late Dr Monro; 
 in Hdler De Hernia Congenita, in his Opufcula Paiho- 
 logica i in Mr John Hunter's very accurate account of 
 the ftate of the Teltis in the Foetus in Dr Hunter's 
 Medical Commentaries ; and in Mr Pott's valuable 
 Trreatlfe on ruptures. Thefe are the beft modern au- 
 thors on this fubjecl ; and very little fatisfaction is to 
 be got from any of ths antient writers upon it. 
 
Be(fl.I. Of the Hydrocele » 383 
 
 a Hydrocele ; but the chirurgical accep- 
 tation of the term, implies a watery fweli- 
 ing fituated in the fcrotum or fpermatic 
 cord. 
 
 Swellings of this kind, as well as every 
 other fpecies of tumor in the fcrotum or 
 groin not immediately produced by the 
 protruHon of parts from the abdomen, are 
 by ancient writers termed Falfe or Spurious 
 HerniaSj in oppofition to thofe defcribed in 
 the laft Chapter, which they diftinguifhed 
 by the appellation of True Hernia. 
 
 No real utility, however, is derived from 
 this diftinclion ; and as it arofe from a 
 very erroneous notion which prevailed of 
 the origin of thefe diforders, we fhould 
 hot have thought it neceflary to mention 
 it here, but with a view to render intelli- 
 gible the ideas of ancient writers upon 
 this fubjedl. 
 
 Indeed, the opinions concerning thefe 
 dlfeafes, as handed down to us by all the 
 older writers, by which I mean thofe of 
 the laft and former centuries, are in gene- 
 ral fo confufed and perplexed, that few of 
 
 thena 
 
3^4 Of the Hydrocele, Chap.Vf. 
 
 them are worth much attention : For, as 
 they were very ignorant of the anatomy of 
 the parts concerned, the ideas they formed 
 of the fituation of the difeafes to which 
 they are Uable, were fo erroneous, that the 
 pracflice built upon them came to be very 
 pernicious. — So Uttle were they acquainted 
 with the ftrudlare of thefe parts, that they 
 proceeded with much unneceiTary dread 
 in the treatment of their diforders ; for, 
 by fuppofing an immediate connedlion to 
 fubfift between the coats of the tefticle, the 
 cavicy of the abdomen, Uver, kidneys, and 
 other vifcera, they were induced to confi- 
 der the colle(5lions of water that occur in 
 the hydrocele, as depolitions from thefe 
 parts, and as tending to free them, and 
 perhaps the fyftem at large, from fome 
 important diforders. Different pafTages in 
 Hildanus, Lanfranc, Fabricius, ab Aqua- 
 pendente, and even in Dicnis's works, £how 
 this to have been the idea of pracfliti oners 
 in the times of thefe authors. 
 
 In confequence of this, their pradlice 
 became timid and undecided j ^o that every 
 
 chirur- 
 
Sea. I. Of the Hydrocele, 385 
 
 chirurgical operation, in which thofe parts 
 were concerned, became a matter of great 
 importance to refoive upon, and very te- 
 dious, painful, and uncertain in the exe- 
 cution. 
 
 From the time of Celfus to the middle 
 of the laft century, very little progrefs 
 feems to iiave been made in reducing the 
 knowledge of thefc difeafes to greater cer-' 
 tainty. Indeed, from Celfus downwards, 
 authors feem to have copied almofl exadl- 
 ly from one another, till Wifeman, la 
 Dran, Garengeot, and Heifter, gradually 
 elucidated the fubjetfl: but they were ne- 
 ver clearly and accurately defcribed, till 
 the difcoveries of Monro, Haller, Hunter^ 
 and Pott, rendered the anatomy of the 
 parts concerned plain and intelligible. So 
 much attention, however, is ftill given to 
 the confufed accounts of thefe parts hand- 
 ed down by ancient writers, that the real 
 nature of the diforders of the teflicle and 
 its appendages is lefs underftood than it 
 otherwife would be. There is no parr^ 
 indeed, of chirurgical pathology^ of which 
 
 Vol. L . B b itu- 
 
386 Of the Hydrocele. Chap. VI. 
 
 fludents in general are fo ignorant as of 
 this ; and hence their notions of thefe dif- 
 eafes, and of the anatomy of the parts in 
 which they are feated, are commonly very 
 indiftinct — Nothing but a flri(fl: attention 
 to the difcoveries of late anatomifts can 
 convey clear and diftin^l ideas concern- 
 ing them ; and whoever will make him- 
 felf thoroughly acquainted with thefe, will 
 find, that the hydrocele, and other difor- 
 ders to which thefe parts are liable, are ex- 
 plained with as much clearnefs and fim- 
 plicity as any other difeafe incident to the 
 human body. 
 
 We have already, in the beginning of 
 the preceding Chapter on Hernise, given a 
 defcription of thefe parts, fo far as related 
 to that clafs of difeafes^ To w^hat was 
 then faid, we mulf now beg leave to re- 
 fer ; but before proceeding to treat far- 
 ther of the diforders now under conlide- 
 ration, we (hall firft enumerate fuch parti- 
 culars relating to the ftrudure of the parts 
 concerned as were not formerly neceflary 
 to be mentioned. 
 
 In 
 
Sea. I. Of the Hydrocele, ^t'f 
 
 In the anatomical defcription already 
 given of thefe parts, we made it appear^ 
 that on the tefles with their blood- vefTels 
 defcending to the groin and fcrotum, as 
 they were while in the abdomen furround- 
 ed by the peritonaeum in the fame manner 
 with the other vifcera, and as in their de- 
 fcent they bring a procefs of the perito- 
 nasum along with them, fo when in the 
 fcrotum, that they ftill remain in the ca^ 
 vity of that membrane. 
 
 At the time of their falling down, and 
 for a ftiort while thereafter, a dired: com- 
 munication fubfifts along this procefs of 
 the peritonaeum between the tefles and 
 vifcera in the abdomen ; but foon after 
 this, except^ as we formerly obferved, in 
 the cafe of a congenital hernia, the fupe- 
 rior part of the paffage begins to contract, 
 and in a fhort time is entirely obliterated, 
 from the opening in the external oblique 
 inufcle down along the fpermatic cord, to 
 the upper part of the epididymis ; the 
 under part of the procefs continuing loofe 
 and open. In this manner the inferior ex- 
 B b 2 tremity 
 
3^3 Of the Hydrocele, Chap. VL 
 
 tremity of the procefs is converted into a 
 kind of bag, the tunica vaginalis telles. 
 
 From the defcription formerly given of 
 thefe parts it appears, that the teftis while 
 in the abdomen is at its back-part firmly 
 connected to the peritonaeum, at w^hich 
 part the blood- vefTels, nerves, and vas de- 
 ferens, communicate with it ; fo when in 
 the fcrotum, a« the vaginal coat with which 
 it is there furrounded is evidently a pro- 
 cefs or continuation of the peritonaeum, 
 it muft of neceffity be flill connecled with 
 that membrane in the fame manner as 
 while it remained in the abdomen. And 
 accordingly we find, that although the 
 tefticle lies loofe in this fac or vaginal coat 
 in every other part, yet all along its pofle- 
 rior part it is firmly attached to it. At 
 this part the different veffels of the teftis 
 flill enter; and at this part the peritonaeum, 
 or what is now the tunica vaginaUs, is re- 
 fiedled over it, thereby forming the tunica 
 albuginea, or immediate covering of the 
 tefticle; fo that the latter, viz. the tunica 
 albuginea, is demonftrably a mere conti- 
 nuation of the former or vaginal coat. 
 
 The 
 
Sed.L Of the Hydrocele. 3*89 
 
 The inferior part of the peritonssal pro- 
 cefs being fomewhat wider below than 
 above, leaves the tunica vaginalis of a py- 
 ramidal form ; and it is alfo fomewhat 
 longer than the teftis, reaching from the 
 fuperior part of the epididymis, where it 
 begins, to a little below the inferior point 
 of the teflicle where it terminates, it is 
 altagether of fuch a fize as to allow the 
 teftis to roll eaiily within it ; its principal 
 life appearing to be, to retain a fmall quan- 
 tity of a fine exhalation, which is con- 
 ftantly fecreting, either from its own fur- 
 face, or from the furface of the teftis itfelf, 
 for the purpofe of keeping the latter fnoift 
 and eafy. 
 
 This vaginal coat which we have now 
 defcribed is the only loofe covering be- 
 longing either to the fpermatic cord or to 
 the teftis : For although, by many writers 
 on this fubje6l, a vaginal coat of the cord 
 is alfo defcribed, together with a fuppofed 
 feptum between it and the vaginal coat of 
 the teftis ; yet no fuch covering is, on dii^ 
 fe^ion, found to exift. The fuperior part 
 B b 3 ^ of 
 
390 Of the Hydrocele, ' Chap.VL 
 
 of the perkonsal fpermatic procefs, we 
 have already feen, is entirely clofed up 
 very foon after the defcent of the tefticle ; 
 and a firm adhefion being produced be- 
 tween the fides of the fac all along the 
 courfe of the cord, no veflige whatever 
 can be traced, either of a vaginal coat of 
 ^he fpermatie cord, or of any particular 
 feptum between that and the tefticle : This 
 it is of fome importance to attend to, as 
 the difeafes of thefe parts cannot otherwife 
 be properly underftood. 
 
 As the difeafes we are now to treat of 
 are chiefly feated in the coverings of the 
 teftis, we have been more particular in ren- 
 dering their il:ru(flure clear and obvious, 
 than is neceflary in defcribing the tefticle 
 itfelf ; with refpeifl to which we fhall only 
 obferve, that it is evidently very vafcular, 
 being compofed almoft entirely of differ- 
 ent convolutions of blood- vefTels. 
 
 Befides the vaginal coat proper to each 
 tefticle, the two teftes have for their far- 
 ther protedion a more external covering, 
 the fcrotum : A bag formed almoft entire- 
 
Sedl. I. Of the Hydrocele, 391 
 
 ly of fliin and cellular fubftance ; for that 
 body thedartos, which has commonly been 
 fuppofed to be m^fcular, is now clearly 
 proved to be altogether cellular. 
 
 Even the feptum fcroti, or that mem- 
 brane which divid^es one teftis from ano- 
 ther, is compofed of cellular fubftance in 
 a more condenfed flate. By air it is eaiily 
 inflated, and it is equally pervious to wa- 
 ter : fo of courfe it partakes of all thofe 
 watery effufions, to which the more exter- 
 nal parts of the fcrotum are liable. 
 
 It is very neceflary to be acquainted with 
 this flruclure of the fcrotum, as from the 
 defcriptions which till of late have been 
 given of it, young practitioners are induced 
 to confider it as mufcular, and to fuppofe 
 the feptum with its rapha to be ligamen- 
 tous ; and hence they are led to be more 
 cautious than they need be in performing 
 operations upon it. 
 
 We have thus entered with as much 
 
 minutenefs into the anatomy of thefe parts 
 
 as is neceffary for underftanding their dif- 
 
 eafes ; and the nature of this undertaking 
 
 B b 4 not 
 
39^ Of the Hydrocele » Chap. VI, 
 
 not admitting of a more particular difcuf- 
 fion, we fhall now proceed to confider the 
 different fpecies of the hydrocele, the im-!- 
 mediate objedl of this chapter. 
 
 All the varieties of the hydrocele which 
 have been mentioned by authors, may, I 
 think, be comprehended under the two 
 following fpecies, viz. the anafarcous, and 
 encyfled. In the former, the water is dif- 
 fufed over all the fubflance of the part in 
 which it is feated ; the fwelling is not col- 
 le(5led in any particular cavity, but occu- 
 pies equally all the cells of the part: In the 
 latter, viz. the encyfted, the water is col- 
 Ie<fled in one diftind: bag ; and a flucftua- 
 tion of a fluid is in general perceptible to 
 the touch. 
 
 The fcrotum, with its contents the tef- 
 ticle and its appendages, are liable to both 
 fpecies of the diforder ; and the fpermatie 
 ,Cord with its coverings are alfo liable to 
 both. \Vc fliall firlt treat of the fcrotal 
 affedlions of this kind. 
 
 SEG^ 
 
Bedl, II. Of the Hydrocele. 393 
 
 SECTION]!. 
 
 Of the Anafarcous Hydrocele of the Scrotum. 
 
 'T^HE fcrotum fram being entirely cel- 
 lular, and conne(5ted immediately with 
 the trunk of the body, is rendered liable 
 to partake of every difFufable fwelling with 
 which the general conOitution is attacked: 
 And accordingly we find, that anafarcous 
 fwellings of other parts of the body, fel- 
 (Jom fubfift for any length of time, with- 
 out producing a iimilar afFedion of the 
 fcrotum. A local anafarcous fuilnefs of 
 the fcrotum unattended with any general 
 affedlion, has on fome occaiions indeed 
 been produced by a local caufe ; viz. by 
 the accidental preifure of a tumor on the 
 lymphatics of the part ; by external in- 
 jury ; and by an effufion of urine from a 
 rupture of the urethra : but fuch occur- 
 rences are very rare, a general difeafe of 
 the conflitution being the ufual forerun- 
 ner of fuch tumors. 
 
 ^^ As foon as water is colleded in any con- 
 liderable quantity in the fcrotum, a foft, 
 
 inelaftic. 
 
394 Of the Hydrocele. Chap. Vi, 
 
 inelaftic, colourlefs tumor; is obferved over 
 the whole of it ; preflure of the finger or 
 of any hard body is eafily received, and 
 the mark of fuch prefTure is for fome time 
 retained by it: The fkin at firft prcferves its 
 natural appearance ; and the rugae of the 
 fcrotum, which in a (late of health are al- 
 ways remarkable, are not for fome timff 
 much altered; but as the iwelling advances 
 they gradually difappear, till at laft they 
 are totally obliterated: Tiie fwelling, from 
 being at firft foft and of a doughy feel, by 
 degrees turns more firm ; and the colour 
 of the flvin from being for fome time very 
 little altered, at laft acquires an unnatural 
 white, fhining appearance. As the difor- 
 der increafes, the tumor by degrees becomes 
 larger ; and from being originally confined 
 to the ufuat boundaries of the fcrotum, it 
 at laft fpreads up the groin ; and the penis 
 being likewife afFedted, becomes fo fwelled 
 and diflorted, as to be produdive of much 
 inconvenience and diftrefs: And although 
 the fcrotum is compofed of parts whic^i 
 readily admit of extenfive dilatation, yet 
 
 in 
 
Sed. II. Of the Hydrocele, 395 
 
 in fome inflances the fwelling here be-- 
 comes fo enormous as to buril the fur- 
 roiinding parts entirely. 
 
 The various appearances we have enu- 
 merated are lb charad^ridic of the dileafe 
 as to render it almoft impofTible to con- 
 found this fpecies of fwelling with any- 
 other tumoj;' to which the fcrotum is li- 
 able. 
 
 We have already obferved, that inflances 
 now and then occur of the Icrotal anafarca 
 being produced by a local caufe ; but by 
 much the greatefl proportion of all fuch 
 cafes depend upon a general hydropic ten- 
 dency ; fo that the cure of this kind of 
 hydrocele muft depend almoft entirely on 
 the removal of that habit of body which 
 originally produced it. 
 
 The treatment of the general diforder 
 of the conftitution falls to the province of 
 the phyfician, fo we fhall not here enter 
 into the confideration of it ; but the af- 
 fiftance of Surgery is frequently required 
 for relieving that great diftrefs which 
 tliefe Rumors always produce when they 
 
 arrive 
 
39^ Of the Hyd?'ocde, Chap. VI, 
 
 arrive at any confiderable degree of mag- 
 nitude. 
 
 In fuch circiimflances, the obje6l of Sur- 
 gery is, by drawing oflPthe water from the 
 tumor, to diminilh the fize of it as much 
 as poflible ; which not only affords much 
 immediate relief, but is a means of the 
 diflended parts recovering their tone more 
 readily than they otherwife would do. 
 
 Different methods have been propofed 
 for evacuating the water, viz. by the in- 
 trodudlion of a fecon, by the trocar, by in- 
 cifions, and by pundures. 
 
 All thefe methods, that by the trocar 
 excepted, ferve very effedually to evacuate 
 the diffufed water ; and therefore we are 
 to adopt that mode which not only creates 
 lead pain, but which is lead liable to be 
 produdive of troublefome confequences ; 
 And this unquedionably is the method by 
 punclures. 
 
 The feton and long fcarifications may 
 evacuate the water fomewhat more quickly 
 than puncSlures ; but in dropiical conftitu- 
 tions, fuch as this fpecies of hydrocele is 
 
 corn-» 
 
Seel. II. Of the Hydrocele: ^gj 
 
 commonly connedled with, they almoft: 
 conftantly go wrong. 
 
 For the firft twenty-four hours or {o^ 
 fcarifications give the patient much fatif- 
 fadion ; the water is almofl entirely eva- 
 cuated, the tumor is of courfe greatly di- 
 minifhed, and much relief is thereby ob- 
 tained. About this time, however, the fca- 
 rified parts commonly begin to fret, their 
 edges turn hard and inflamed, and by 
 degrees an eryfipelatous kind of rednefs 
 fpreads over the neighbouring parts. 
 
 That fretful uneafinefs which was at 
 firft complained of, by degrees turns into 
 what the patient terms a burning kind of 
 pain, which frequently becomes fo tor- 
 menting as to deftroy reft entirely ; and it 
 but too commonly happens, that all the 
 applications employed for relief, have no 
 manner of influence in preventing the 
 acceflion of gangrene, by which the pa- 
 tient is at laft in general carried off. 
 
 I will not fay that fuch fymptoms are 
 
 always induced by .fcarifications, but I 
 
 .have in many inftances obferved them; 
 
 I and 
 
398 of the Hydrocele. Chap. Vt. 
 
 and on the contrary, although punclures 
 do now and then terminate in the 'fame 
 manner, yet they are by no means fo ready 
 to do fo *. 
 
 As fcarifications are fo apt to produce 
 mifchief here, there is much reafon to fuf- 
 pe<5l that either the trocar or feton, which 
 both give ftill more irritation, would com- 
 monly prove more hurtful. They are now 
 accordingly in this fpecies of the hydro- 
 cele very generally laid afide. 
 
 When fcarifications are to be employed^ 
 the method of doing it is, with the flioul- 
 der of a lancet to make two or three inci- 
 iions on the mod depending part of thd 
 fcrotum, each of an inch in length, and 
 extending no deeper than the cutis vera : 
 And when punctures are to be depended 
 on, they are likewife to be made of this 
 depth with the point of a fpear-pointed 
 lancet ; and five or fix on the mofl: promi- 
 nent part of the tumor will commonly 
 prove fufiicient. This number will in ge- 
 I . neral 
 
 * Vide Le Dran's Operations, with Chefelden's notes, 
 p. 116; and Treatife on Hydrocele by Mr Pott, p. 40.- 
 
Sed. II. Of the Hydrocele^ ' 39^ 
 
 neral evacuate the water very quickly ; 
 but w^hen they do not prove fully ade- 
 quate to the effed propofed, or when in 
 the courfe of a day or two, thefe now 
 made are found to heal, they may be re- 
 newed from time to time as often as is ne- 
 ceflary. 
 
 Preferving the parts as dry as poffible, 
 by a frequent renewal of dry foft linen 
 cloths, in order to imbibe the moiflure, is 
 here a very neceflliry piece of attention ; 
 the want of it, I am convinced, is thecaufe 
 of much of the mifchief that frequently 
 enfues from operations of this kind. 
 
 When either fcarifications or pun<5lures 
 go wrong, by beginning to inflame and 
 turn painful in the manner we have de- 
 fcribed ; inftead of the warm emollient 
 poultices and fomentations ufually em- 
 ployed, a cold folution of faccharum fa- 
 turni, applied upon foft linen, not only 
 proves mjore efFe^lual in putting a flop to 
 the farther progrefs of the inflammation, 
 but affords more immediate relief to the 
 prefent ditlrefs. Aqua calcis employed m 
 
 the 
 
466 Of the Hydrocele. Chap. Vf . 
 
 the fame manner proves alfo a very ufeful 
 applicaiion. 
 
 When, however, the diforder proceeds to 
 gain ground, by a real mortification co- 
 ming on, we (hould immediately have re- 
 courfe to bark and other remedies ufually 
 employed in fuch afFeclions. But as we 
 have elfewhere treated fully upon this fub- 
 je(fl, it is unneceflary to enter into a more 
 particular confideration of it here*. 
 
 It may only be proper to obferve, that 
 although in general, when the fcrotum in 
 this difeafe happens to mortify, the great- 
 eft danger is to be dreaded ; yet now and 
 then very unexpecfled cures are obtained, 
 after all the teguments have been deftroy- 
 ed by mortification. A remarkable cafe 
 of this kind occurred fome years ago in 
 the Royal Infirmary here: The whole fcro- 
 tum feparated, and left the teftieles quite 
 bare. During the time that the fore re- 
 mained open, all the water collected in 
 other parts of the body was evacuated, and 
 
 by 
 
 ■* Vide Treatife on Ulcers, &c. Seaion IV,- On 
 Mortification' 
 
Sed. 11. Of the Hyrocete^ 40 j 
 
 by the ufe of large quantities of bark and 
 inild dreffings to the fore, the patient goc 
 welL In the courte of the cure, the tellis 
 became inveloped with a kind of cellular 
 fubftance, which ferved as a very good 
 means of protecflion. It mull have beea 
 fome production of this kind, I fuppofe, 
 which Hildanus fpeaks of as a regenerated 
 fcrotum *. 
 
 We have already obferved, that although 
 this fpecies of hydrocele for the mod part 
 depends upon a general dropfical tendency^ 
 that fome inftances, however^ occur, of a 
 local caufe producing a mere local dropfy 
 of the fcrotum. Thus it has been known 
 to happen, from fwellings in the groin and 
 in the abdomen obftruding the pafTage of 
 the refluent lymphatics. When this is the 
 cafe, if the tumors producing fuch ob- 
 ftrudlions can be extirpated, no other means 
 will afford fuch effedlual relief; but when 
 they are fo deeply feated as to render any 
 attempt for removing them improper, the 
 pracflice we have already pointed out, of 
 
 Vol, I. Go pundures 
 
 *^ObferYat. Chirurg. cent 5= obf. 7<5, 
 
402 Of the Hydrocele. Ch^p. VL 
 
 punf^ures in the moft depending part of 
 the tamor, mull be employed with a view 
 to palliate fuch fymptoms as occur. 
 
 It fometimes happens in cafes of fup- 
 preffion of urine, either from caruncles in 
 the urethra, from l\ones impacted in it, 
 or from collections of matter, that the ure-* 
 thra burfls, and the urine in this manner 
 finding a pafTage into the fcrotum, an ana- 
 farcous fwelling of it is thus fuddenly 
 produced, which flill continues to iri- 
 creafe till the caufe giving rife to it is re- 
 moved *. 
 
 In order to prevent the formation of 
 finufes, which in fuch circumflances will 
 otherwife be apt to occur, an incifion fhould 
 be made into the mofl depending part of 
 the fcrotum, and carried to fuch a depth 
 as is fufEcient for reaching the wound in 
 the urethra. In this manner a free vent will 
 not only be given to the urine already dif- 
 fufed, but the farther collecflion of it may 
 very probably be prevented. If a ftone 
 impacted in the urethra is found to be the 
 
 caufe 
 * The works of the late Dr Alex. Monro, p. 569, 
 
Sed. II. Of the Hydrocele 46 j 
 
 caufe of this efFufion, it ought to be cut 
 out; if a colledion of matter is difcovered^ 
 the abfcefs fhould be opened ; and if the 
 obftrudlion is produced by caruncles in 
 the urethra, bougies fhould be employed 
 for their removal. 
 
 The caufe being thus removed, if the 
 patient's habit of body is good and un- 
 tainted vs'ith any venereal or other gene- 
 ral afFedlion, by drefUng the fore proper- 
 ly with foft eafy applications, the open- 
 ing into the urethra will probably be 
 brought to heal, and a complete cure will 
 be in this manner obtained. But when 
 fuch ailments are complicated with any 
 general diforder of the fyflem, particu- 
 larly with old venereal complaints, it fre- 
 quently happens, that neither mercury nor 
 any other medicine has much influence in 
 removing them. 
 
 Every practitioner mud have met with 
 inftances of this kind. Both in the hof- 
 pital and in private I have met with fuch 
 cafes, where, notwichftanding all the 
 means employed for relief, the paiTage 
 C c a frorai 
 
404 Of the Hydrocele, Chap. VI. 
 
 from the urethra remained open, and con- 
 tinued to difcharge coniiderable quanti- 
 ties of urine. 
 
 Inftances of the fcrotal anafarca of a lo- 
 cal nature, have alfo occurred, from the 
 rupture of a hydrocele of the tunica vagi- 
 nalis teftis : When this fpecies of hydro- 
 cele arrives at a great fize, jumping from 
 a height, or a violent blow or bruife of 
 any kind, will readily burft it ; and the 
 water not finding a pafTage outwardly, 
 mufl nec^lTarily difFufe itfelf over the 
 whole fcrotum. Different inftances of this 
 kind have been met with ; two of which are 
 related by Douglafs*. And the fame kind 
 of fwelling has been pr'^duced by the wa- 
 ter of a hydrocele of the vaginal coat be- 
 ing improperly drawn off by the opera- 
 tion of tapping. When the orifice in the 
 fkin is allowed to recede from the open- 
 ing into the vaginal coat before the water 
 is all difcharged, the remainder of the 
 colle6lion is very apt to difFufe itfelf thro' 
 all the cellular fubftance of the fcrotum. 
 
 In 
 
 * Treatife on the Hydrocele, by John Douglafsj 
 p. 8. 
 
Sedl. IT. Of the Hydrocele, 405 
 
 In whichever of thefe ways the fwellirig 
 is produced, the cure ought to confift in 
 laying the tumor fufficientlv open, not 
 only for evacuating the difFafed water,, 
 but for efFiding a radical cure of the hy- 
 drocele of the tunica vaginalis. 
 
 We have thus enumerated all the varie- 
 dej> of anafarcous fwellings to which the 
 fcrotum is liable, together with the modes 
 of treatment adapted to each: For with 
 refpe6t to the hydrocele of the darcos, a 
 difeafe particularly defcribed by. ancient 
 writers, as that part of the fcrorum is now 
 known to be altogether cellular, fo any 
 water colleded in it mail tend to form 
 that very difeafe we have now been de- 
 fcribing, an anafarcous fwelling of the 
 whole fcrotum. 
 
 We now proceed to the confideration of 
 that fpecies of the diforder, which, from 
 its being feated within the cavity of the 
 fcrotum, we have termed the tncyjled hy^ 
 droceie of the fcrotum. Of this there are 
 two varieties, viz. the hydrocele of the tu- 
 nica vaginalis teftis ; and that fpecies of 
 C c 3 tumor 
 
4e)6 Of the Hydrocele, Chap. VI, 
 
 tumor formed by water colledled in the 
 fac of a hernia. 
 
 SECTION III. 
 
 Of the Hvdroc-^le of the Tunica Vaginalis Tejlis. 
 
 1 A/ HKN creating of the anatomy of thefe 
 p.iits, we remarked, that in a ft.ite 
 of health an aqueuus lecrecion is always 
 found in the tunica vaginalis; the princi- 
 pal ufe of which feems to be, to lubricate 
 and keep the furface of the teilicle foft and 
 eafy. 
 
 In a healthy ftate, this fluid is abforbed 
 by the lymphatics of the part ; its place 
 bemg as conftanily fupplied by a frefh fe- 
 fecrecion: But in difeafe, it frequently hap- 
 pens, either that the fecretion of this fluid 
 is morbidly incieafed, or that the powers 
 of the abforbing veffels of the part are di- 
 miniflied. The effedl of either of thefe 
 caufes muft be, to induce a preternatural 
 collection of water in the cavity of the va- 
 ginal coat ; and by a gradual accumula- 
 tior^ of this flaidj the fpecies of hydrocele 
 which we are now confidering will be at 
 
Sea. III. Of the Hydrocele. 407 
 
 lafl: produced. The fympcoms and appear- 
 ances of the diforder are as follow. 
 
 A fulnefs is at fird obferved about the 
 inferior part of one of the tefticles, which 
 is at this time foft and comprefTible ; but 
 as the tumor increafes in fize, it alfo be- 
 comes more tenfe : No degree of prefTure 
 can make the fwelling difappear either at 
 this or any other period of the difeafe: 
 The teguments at H^-fi prefer ve their na- 
 tural appearance, boih as to colour and 
 rugofitv ; :)uc as the water accumulates, 
 the (km j^ra iualiy becomes more tenfe, 
 although reldoin or never to fuch a degree 
 as to obliterate the rugse of the fcrotum 
 entirely. 
 
 The fhape of the tumor, which was at 
 firfl: nearly globular, bee 'ines gradually 
 more pyramidal, being larger heiow than 
 above: In the firft ilages ot the diforder, the 
 fwelling does not extend farther thaa the 
 ufual boundaries of the fcrotum ; but in 
 procefs of time, it advaaces by degrees up 
 to the abdominal muicles ; fo that altho' 
 in the early period of the difeafe, if it be 
 G c 4 not 
 
40 8 Of the Hydrocele. Chap. VI, 
 
 not combined with hernia, or with a hy- 
 drocele of the cord itfelf, the fpermatic 
 procefsmay be always diftincflly felt; in its 
 more advanced ftate it cannot pofTibly be 
 diftinguiihed. The weight of the tumor 
 being now very great, the Itin of the neigh- 
 bouring parts is dragged fo much along 
 with it as to caufe the penis to flirink conii- 
 d^rably, and fometimes to difappear almoft 
 entirely : And in this advanced ftate of the 
 difeafe, the ceilicle, which ufually lies at 
 the back part of the tumor, and which for 
 fome time after the comrnencement of the 
 diforder could bediftincflly felt, cannot now 
 be evidently difcovered On a minute exa- 
 mination, however, a hardnefs is always to 
 be felt along that pare of the fcrotum where 
 the teftis is fituated : And a fladluation of 
 a fluid may in general be dillinguiflied 
 through the whole courfe of the difeafe. 
 
 It fometimes happens, however, in that 
 very tenfe flate of the tumor, which a long 
 continuanceof the difeafe ufually occafions, 
 that the fluid contained in it cannot be 
 evidently diftinguiflied : Nor in this litua- 
 
 tipa 
 
5e<fl. III. Of the Hydrocele, 409 
 
 tion is the ordinary characteriftic marl^: of 
 hydrpcele more to be depended pn ; 1 m^an, 
 trie trarXparency of the tumor when expo-r 
 fed to the light of a candle or of the fun. 
 In the early ftages of the difeafe, when the 
 contents of the tumor have not become dif^ 
 coloured, and when the vaginal coat ha$ 
 not yet acquired much thicknefs, the con^ 
 tained fluid, on being expofed to this trial^ 
 always appears tranfparent; and when it 
 does fo, it always affords a corroborating 
 proof of the exiflence of water : yet its ab^ 
 fence is by no means a proof of the con* 
 trary ; for as the tranfparency of the tumor 
 depends entirely on the nature of its con^- 
 tents, and on the thicknefs of its coverings, 
 whatever tends to render the one lefs clear, 
 and the other of a more firm texture, muft 
 in proportion to this effect invalidate the 
 certainty of the teft. 
 
 During the whole courfe of the diforder 
 the patient does not complain of pain in 
 the tumor itfelf ; but fome uneafinefs is 
 commonly produced in the back, by the 
 weight of the fwelling on the fpermatic 
 
 cord ; 
 
410 Of the Hydrocele, Chap. VI. 
 
 cord: this, however, is generally either pre- 
 vented altogether, or is at leaft much alle- 
 viated, by the ufe of a proper fufpenfory 
 bandage. 
 
 Thefe are the ufual appearances of a hy- 
 drocele when the difeafe is confined to one 
 fide of the fcrotam, which is generally the 
 cafe Bat on- fome occafiohs a double hy- 
 drocele is met with, in which both tefticles 
 are afFecled in the fame manner ; and in 
 which the tumor, inflead of being confi- 
 ned to one fide of the fcrotum, occupies 
 the whole of ic equally. 
 
 As there are fome diforders with which 
 this fpecies of hydrocele is apt to be con- 
 founded, it is particularly neceffary to at- 
 tend to fuch circumftances as mod readily 
 charaderife it. Thefe diforders are. All the 
 variety of fcrotal hernias ; the anafarcous 
 hydrocele of the fcrotum ; the encyfted 
 hydrocele of the fpermatic cord ; the far- 
 cocele, orfcirrhous teflicle; and the hernia 
 humoralis, or inflamed teftis. 
 
 When treating of hernise, we enumerated 
 fuch circumftances as, when properly con- 
 
 fidered. 
 
Sea. III. Of the Hydrocele, 4 1 1 
 
 fidered, will almoft always ferve to diflin- 
 guifli this fpecies of hydrocele from every 
 varietyof thefediforders: To what was then 
 faid, we mufl here therefore refer *. 
 
 It has on fome occafions, we are told, 
 been confounded with the anafarcous tu- 
 mor of the fcrotum; but the means of 
 ditlinguifhing the two difeafes are fo evi- 
 dently pointed out in the hiftories we have 
 given of their appearances, as to render it 
 quite unnecelTary to enter farther into their 
 conhderation Indeed it muft be grofs in- 
 attencion only, which can ever render the 
 anafarcous fpecies of hydrocele liable to any 
 degree of doubt- 
 
 From the encyfted hydrocele of the fper- 
 matic cord, it may commonly be eafily 
 diftinguifhed, by the tefticle in the latter 
 being plainly felt at the under part of the 
 tumor; whereas in this difeafe, when the 
 teftis is perceptible, it is always at the 
 back-part of it: And in this fpecies of 
 hydrocele, the fwelling begins in the un- 
 4er part of the fcrotum, and proceeds up- 
 wards; 
 
 « See p. 313, 
 
412 Of the Hydrocele. Chap. VI. 
 
 wards : whereas in the encyfted hydrocele 
 of the cord, it makes ics firfl appearance 
 above the epididymis, and by degrees falls 
 down to the inferior parts of the fcrotum. 
 By this difference alone thefe two fpecies 
 of hydrocele may be always diftinguifhed 
 from one another. 
 
 The circtrmftances which moft clearly 
 diflinguifli this kind of tumor from a 
 fcirrhous tefticle, are thefe: In the latter 
 the fwelling is hard and firm ; it does not 
 yield in any degree to prefTare; the furface 
 of the tumor is rough and unequal; it is 
 in general attended with a good deal of 
 pain, and is always heavy in proportion to 
 its fize. Whereas in the hydrocele, the 
 fwelling commonly yields to prefTure; its 
 furface is fmooth ; little or no pain takes 
 place; and the tumor is light in propor- 
 tion to its bulk. 
 
 Thefe differences will always ferve as a 
 fafficient means of diflincflion between this 
 fpecies of hydrocele and a pure unmixed 
 farcocele But when a fcirrhous tefticle 
 is combined with an effufion of water into 
 
 the 
 
Sea. III. Of the Hydrocele, 41^ 
 
 the tunica vaginalis, forming what has very 
 properly been termed a hydro-Jarcocele^ the 
 means of diftin(5lion are not To obvious. In 
 the incipient ftate of fuch effafions, the dif- 
 ference between the two difeafes is fuffici- 
 ently apparent; but in the latter ftages of 
 it, the mod attentive obferver commonly 
 finds it difficult, and fometimes impoflible, 
 to mark the diftindion. In fuch doubtful 
 cafes, however, by proceeding in the cau- 
 tious manner to be afterwards pointed out, 
 no detriment will occur to the patient from 
 any uncertainty of this nature. 
 
 From the hernia humoralis this fpecies of 
 hydrocele is eafily dillinguiihed. In the for- 
 mer, the tumor fucceeds either immediately 
 to fome external bruifej or it is evidently 
 the confequence of a gonorrhoea, or of 
 fome other inflammatory afFe^ion of the 
 urethra*. Thefkin is more or lefs affec- 
 ted 
 
 * The operation of lithotomy is frequently attended 
 with an inflammation of one, and fometimes of both^ 
 of the teftidesj probably from the inflammation in- 
 duced by the operation in the neighbourhood of tlie' 
 caput gallinaginis, being communicated along the ras 
 difFerens to the teftes. 
 
414 0/ ^^^ Hydrocele, Chap. Vf. 
 
 ted with an infla-nmatory rednefs; it is 
 attended with a confiderable degree of pain 
 efpecially on handling; and the fwelhng is 
 hard and firm ; fo of courfe no flu(5luation 
 can be dilHnguifhed in it, unlefs in its 
 more advanced ftate, when fuppuration 
 fometimes takes place, and when the ufaal 
 fymptoms of abfcefs, particularly the point- 
 ing of the tumor, and its being mnch difco- 
 loured, ferve to diftinguifli it fufficiently. 
 
 In forming a prognofis of this difeafe, 
 we mufl be direifted aimofl: entirely by the 
 habit of body of the patient. In general, 
 we are to confider it as a local afFedlion ; 
 and in that flate the mod favourable ex- 
 pedlations may be formed of the event; 
 for, whatever may have been alleged by 
 fome writers as to the hazard of every o- 
 peration for a radical cure of the diforder, 
 in a fimple unmixed hydrocele, and in a 
 found healthy conftitution, it may at any 
 time be advifed with a very fair profped: 
 of fuccefs. 
 
 In the radical cure of the hydrocele, in 
 
 whatever way it is attempted, fome pain 
 
 1 will 
 
Sea. III. Of the Hydrocde. 4 1 5 
 
 will be occafioned ; the parts will inflame, 
 and of courfe fome degree of fever muft be 
 expedled. In fome inftances, thefe fymp- 
 toms have gone rather farther than was 
 juft neceiTary ; but under the limitations . 
 I have already mentioned, of an unmixed 
 ftate of the dilorder in a conftitution o- 
 therwife healthy, whenever the operation 
 has been properly performed, 1 can fafely 
 aver, that of a very confiderable number 
 I have operated upon myfelf, as well as of 
 many 1 have been connedled with, 1 never 
 knew one inftance of any thing bad occur- 
 ring. 
 
 But on the contrary, in conftitutions 
 otherwife difeafed; in old people; and ia 
 infirm habits of body; we are by no means 
 to expedl fuch certain fuccefs; Even in 
 fuch circumflances, the operation very fre- 
 quently fucceeds ; but it mufl be acknow- 
 ledged that it now and then fails. The 
 fymptomatic fever is apt to run too high 
 for the flrength of the patient ; and the 
 fuppuration produced by a high degree of 
 inflammation tends afterwards to deflroy 
 
 en- 
 
41 5 Of the Hydrocde. Cnap. VI. 
 
 entirely the remains of a confticution al- 
 ready much impaired. This, however* 
 ought not CD be laid to the account of the 
 operation, but to the real difeafed flate of 
 the patient. 
 
 When, therefore, tliis diforder occurs in 
 a healthy conftitution, I would conclude, 
 from all the experience I have had in it, 
 that little or no danger is to be dreaded 
 from any neceflary o})eration : And on the 
 contrary, in a difeafed ftate of body, that 
 fome rifk is always incurred by every ope- 
 raiion that takes place ; and the degree of 
 rifk. we may fuppofe will be always in pro- 
 portion tathe nature and extent of thatdif- 
 eafe with which the conilitution is affecfted. 
 
 As long as a fwelling of this nature keeps 
 within moderate iimiis, patients in general 
 rather fubmit to the inconvenience pro- 
 duced by it, than undergo the pain of an 
 operation ; at leaft this is commonly the 
 cafe among people of better rank, who can 
 morereadilvputup with any diilrefs which 
 it occafions, than the poorer fet of patients, 
 whofe daily labour is frequently impeded 
 - by 
 
Seifl. III. Of the Hydrocele, 4^7 
 
 by large tumors in the fcrotum. Among 
 thofe of the former clafs, inflances occur 
 of the diforder having exifted for a great 
 length of time without being productive 
 of much inconvenience : But even among 
 thefe it commonly happens that they be- 
 come anxious; fatigued with uncertainty; 
 and are at laft induced to fubmit to the 
 operation. — In all fuch inftances, when the 
 conftitution is otherwife found, this may 
 be undertaken, as we have already remark- 
 ed, with an almoft certain profpecft of fuc- 
 cefs ; but when the fyftem is materially 
 difeafed, a patient had better fubmit to 
 any inconvenience produced by the difor- 
 der, than undergo an operation for a ra- 
 dical cure : And this may be the more ea- 
 iily agreed to from the relief which people 
 with tumors of this kind always experience 
 from tapping, which is termed the Pallia- 
 tive Cure; and which when it is properly 
 done, if the confiitution is not greatly im- 
 paired indeed, may be always fubmitted to 
 without any dread ofits proving hazardous. 
 Various methods are propofed by au- 
 VoL. I. D d thors 
 
4iS' Of the Hydrocele, Chap. VI. 
 
 thors for the treatment of this diforder. 
 All of them, however, may be reduced ta 
 two general heads ; viz. fuch as have in 
 view only a temporary relief, and' which,. 
 as we have juft now obferved, is termed 
 the Palliative Cure ; and fuch as are in- 
 tended for effeding a Radical Cure, or a 
 final removal of the diforder. 
 
 Whatever advantages may be experien- 
 ced, from the ufe of internal medicines, in 
 dropfical affedlions of the conftitution, no 
 pradlitioner, I believe, has fo much con- 
 jSdence in remedies of this kind, as to ex- 
 pe(5l much benefit from them in any par- 
 tial hydropic colle6lions of the encyfted 
 kind : We have daily proofs of their gene- 
 ral failure in almoft every affeciion of this 
 nature ; and in no fpecies of dropfy do 
 they prove more inefFedual than in the 
 hydrocele. — We are told, indeed, of cures 
 having been performed by ditrerent medi- 
 cines, particularly by the ufe of ftrong dra- 
 flic purgatives : I have known them em- 
 ployed, but never wdth advantage; and 
 when puihed to any extent, they are fure 
 
 to 
 
Sea.IlI. Of the Hydrocele, 4 1 9 
 
 to hurt the conftitutlon. — As it is always 
 necelTary however to confine the patient to 
 bed for fome time after any operation that 
 takes place, in order to prevent his being 
 afterwards difturbed, it is proper to empty 
 his bowels by a laxative immediately be- 
 fore the operation; but this is almoft the 
 only medicine that can be requifite. Inter- 
 nal medicines, therefore, being found inef- 
 fectual, as well as external applications, we 
 are to feek for that reUef from Surgery 
 which experience iliows it is capable of af- 
 fording. 
 
 When the tumor in the fcrotum has ac- 
 quired fuch a fize as to become inconve- 
 nient, if the patient either refufes to fub- 
 mit to the operation for the radical cure, 
 or if his ftate of health renders that opera- 
 tion improper, in fuch circumftances, the 
 palliative treatment, or a mere evacuation 
 of the water by puncture, is the only means 
 we can employ. 
 
 There are two methods propofed for 
 
 drawing oif the water in this manner, viz, 
 
 by the puncflure of a lancet, or with a trocar, 
 
 — ^^It is alleged by fome, that by the mere 
 
 .Dd2 punc- 
 
420 Of the Hydrocele. Chap. VI. 
 
 puncture of a lancet the water can neither 
 be fo completely or To properly drawn ofF 
 as when the trocar is employed ; for the 
 orifice in the fkin being apt to recede from 
 the opening in the vaginal coat, the water 
 is thereby elcher ftopt altogether, or is apt to 
 infinuate itfelf into the furrounding parts. 
 By others again it is faid, that the difficulty 
 of introducing the trocar is fuch as to ren- 
 der it hazardous from the contiguity of the 
 tefticle ; and inftances are not wanting to 
 fliow, that even in the hands of expert fur- 
 geons the teftis has been very materially 
 injured by a trocar reaching it in this ope- 
 ration. Indeed, the ordinary form of this 
 inftrument, which is triangular, renders its 
 introduclion both difficult and unfafe; but 
 the trocar of a flat form which I propofed 
 fome years ago, enters with as mucheafe as 
 a lancet. — In Plate X. different inftrumencs 
 of this kind are i-^prefented, of a proper 
 fize for this operation. — And as with a tro- 
 car of this kind an opening may be made 
 into the tunica vaginalis with perfect fafe- 
 ty, and the water with this inftrum^ent be- 
 ing 
 
Tlate X. 
 
 \-Ap 2 
 
 '"X- 
 
 
 (0 ® 
 
 '4/J^^//'M^^^ 
 
 /7y 
 
Sed. HI. Of the Hydrocek. 4.2 1 
 
 ing much more freely evacuated than hf%. 
 mere pun6lure with a lancet, which is ape 
 to produce an effulion into the cellular 
 fubftance of the fcrotum, the mode of ef- 
 feding it by the lancet ought therefore to 
 be laid afide. 
 
 The inftrument being fixed upon, the 
 next point of importance is the part of the 
 tumor mod proper for the operation. E- 
 ven in this fimple operation, an acquaint- 
 ance v/ith the anatomy of the parts will 
 appear to be very neceffary. We have al- 
 ready fhown, that the teftis does not hang 
 altogether loQfe in the vaginal coat; but 
 on the contrary, that its pofterior part is 
 firmly conne6led to the body of the tefti- 
 cle ; fo of confequence at this part there is 
 no water to be met with between the fcro- 
 tum and teftis; and accordingly it would 
 be highly improper to attempt an opening 
 at this V place: For if through ignorance 
 the trocar fliould be inferted here, one in- 
 ftance of which I have i^ttn^ the inftru- 
 ment would for certain pierce the body of 
 the tefticle, and would not, after all, eva- 
 <;uate the water. 
 
 Ddj The 
 
422 Of the Hydrocele, Chap. VI, 
 
 The moH: proper part for introducing 
 the inftrument is the moft anterior point 
 of the under part of the tumor. The pa- 
 tient being feated on a chair, with the tu- 
 mor hanging over the edge of it, the ope- 
 rator with his left-hand fiiould grafp the 
 tumor on its back- part, fo as to pufti the 
 contained fluid as much as poflible into 
 the anterior and under part of the fwell- 
 ing. Having done fo, he then makes an 
 opening through the fldn and celhilar 
 fubflance, of about half an inch in length, 
 with the fhoulder of a common lancet, on 
 that point where the trocar is to enter. 
 This gives very little pain to the patient; 
 ic is done in the fpace of a fecond or two, 
 and it enfures an eafy pafTage to the point 
 of the inftrument; a circumftance which 
 diverts this operation of all kind of ha- 
 zard. 
 
 The operator now takes the trocar in his 
 right-hand, and having fixed the head of 
 the inftrument in the palm of the hand, 
 he places the fore- finger along the courfe 
 pf itj leaving juft as much of the point of 
 
Sed. III. Of the Hydrocele. 423 
 
 the inftrument uncovered as lie thinks 
 ought CO penetrate the tunica vaginalis ; 
 and this being introduced in a gradual 
 eafy manner, the ftilette is to be with- 
 drawn immediately on the end of the ca- 
 nula having entered the cyft. The water 
 will now run off; and if the tumor be not 
 of a great fize, it may be all evacuated at 
 once: but when the fwelling is large, as 
 the fudden difcharge of the fluid, by ta- 
 king away too quickly the fupport which 
 it afforded to the veffels of the teftes and 
 vaginal coat, might endanger the rupture 
 of fome of them, it is better every now 
 and then to flop the flow of it for a few 
 feconds; and when the whole is thus eva- 
 cuated, and thecanula withdrawn, a piece 
 of adhehve plafter fhould be immediately 
 applied to the orifice, and a comprefs of 
 foft linen being laid over the fcrotum, the 
 whole fhould be firmly fupported by a pro- 
 per application of the T-bandage*. 
 
 D d 4 The 
 
 * Some very judicious remarks on the importance 
 of a due degree of compreiTion in fuch cafes may be 
 met with in Dr Monro's obfervations on this fubiedg 
 loco citato^ 
 
424 Of the Hydrocele, Chap. VI. 
 
 The patient being in this flate laid in 
 bed, it commonly happens, that in a few- 
 hours all manner of uneaGnefs is gone, 
 and he goes about his ordinary bufinefs 
 without farther interruption: Now and 
 then, however, the fore produced by the 
 trocar fefters; and the inflammation thus 
 produced, in fome inflances, has been 
 known to terminate in a radical cure of 
 the diforder. Such occurrences, how^ever, 
 are rare, and are by no means to be de- 
 pended on. 
 
 This operation, when done with atten- 
 tion, is eafily performed, and is feldompro- 
 du<5live of any mifchiefj but when not per- 
 formed with caution, and efpccially when 
 the patient is allowed to go about imme- 
 diately after the water is evacuated, it 
 fometimes terminates in very troublefome 
 fymptoms. Even when done with every 
 poflible attention, if the patient's habit of 
 body is bad, it fometimes goes wrong, 
 Of this every practitioner may have feen 
 fome inflances more or lefs remarkable: 
 And two cafes are related by MrPottj on^ 
 
 Oi 
 
Sect. in. Of the Hydrocele, 42^ 
 
 of which terminated fatally ; and in the 
 other a mortification enfued, which in the 
 fpace of a few days deftroyed not only a 
 good deal of the fcrotum, but even a confi- 
 derable portion of the tmiica vaginalis *. 
 Both of thefe indeed occurred in very un- 
 healthy conftitutions ; but it is proper to 
 have it known, that this operation may in 
 iuch habits of body be produdlive of thefe 
 confequences. In found healthy people, 
 it feldom or never ends in any thing bad; 
 but the event of thefe cafes of Mr Pott and 
 others, ought to convince us that it fhould 
 not -be attempted where the fyflem is evi- 
 dently much difeafed. 
 
 Drawing the water off in this manner in 
 order to relieve the patient from the bulk 
 it produced, was the firft idea that occur- 
 red to praditioners in the treatment of the 
 hydrocele; but this being found ineffec- 
 tual for the complete removal of the dif- 
 eafe, various other methods were afterwards 
 introduced. The aclual cautery and the 
 ligature were both propofed as means of 
 
 pre- 
 
 f Cafes xxi. and xxii. Treatife on the Hydrocele. 
 
426 Of the Hydrocele, Chap. VI, 
 
 preventing farther defcents of water from 
 the abdomen, which in former times was 
 confidered as the origin of this diforder. 
 Celfus orders a cyft of a hydrocele to be 
 cut away, and many of his followers do 
 the fame. Tents, both folid and hollow, 
 were afterwards employed; as was likewife 
 the ufe of the feton, which we find recom- 
 mended by Fabricius ab Aquapendente, 
 and other writers even of a more early 
 period. The ufe of various applications of 
 the cauftic kind has at different times been 
 in vogue : Inje(5ling wine, diluted ardent 
 fpirits, and other irritating liquids, into an 
 opening in the vaginal coat, has been pro- 
 pofed as a means of inducing a degree of 
 inflammation fufficient for effedling a ra- 
 dical cure ; and a fimple incifion of the 
 cyft containing the water has been prac- 
 tifed for the fame purpofe. 
 
 Thefe, I think, comprehend all the va- 
 riety of means which at different periods 
 have been employed for the cure of the 
 hydrocele. Ancient praditioners feem to 
 have been acquainted with all of them j 
 
 but 
 
Sedt. III. Of the Hydrocele, 427 
 
 but having very inaccurate ideas of the 
 anatomy of the parts concerned, they 
 could not have any fixed or clear opinion 
 of the manner in which any of their re- 
 medies operated in eiFedling a cure. In 
 confequence of this they were applied very 
 much at random ; and no method proving 
 at all times fuccefsful, the ignorance they 
 laboured under in the theory of the dif- 
 order rendered changes of remedies very 
 frequent in the treatment of it. 
 
 One material advantage obtained by the 
 moderns in this point is, that by knowing 
 the water to be contained in a particular 
 cyft with which no part of the body com- 
 municates, they are thereby left at liberty 
 to apply their remedies without any dread 
 of injuring parts which were formerly fup- 
 pofed to be connected with the tefticle ; 
 and by finding that the water colledled in 
 this difeafe, is in many refpeifls in a fimi- 
 lar fituation to the contents of other tu- 
 mors, with the means of curing which 
 they are well acquainted, they have ven- 
 tured from analogy to transfer the method 
 
 of 
 
4^8 Of the Hydrocele, Chap. VI, 
 
 of treatment found to fucceed in thefe dif- 
 orders, to this fpecies of the hydrocele. 
 
 Matter colledled in a particular cavity 
 or cyft, we fuppofe to be in circumftances 
 very fimilar to water collected in the tuni- 
 ca vaginalis teftis. In both fituations, the 
 contents of the tumor are fecluded from 
 accefs to the external air ; and neither of 
 them have any communication with any 
 other part of the body. And although the 
 bag containing the matter of an encyfted 
 tumor is is in fome meafure a new forma- 
 tion, yet in many inftances it is found to 
 be equally firm and elaftic with the tunica 
 vaginalis teftis. 
 
 In the treatment of encvfted tumors, 
 praclitioners are now agreed, that, befides 
 evacuating the matter, means muft be em- 
 ployed for deftroying the cavity which con- 
 tained it, otherwife a return of the difor- 
 der may in general be expecfted. To ac- 
 complifli this, different methods have been 
 propofed; fome with a view to deftroy en- 
 tirely the cyft which contained the mat- 
 ter ; and others, as it is faid, to fill up the 
 
 cavity 
 
Sea.III. Of the Hydrocele. 429 
 
 cavity of the cyft with a formation of new 
 parts. 
 
 But we now know, that unlefs the coats 
 of a cyft are much extended, and greatly 
 thickened indeed, that there is no reafon 
 whatever for removing any part of it. It 
 is alfo kaown, that to fill up the cavities of 
 tumors with a creation of new parts, is a 
 mere imaginary matter, being what neither 
 art or nature ever effeds to any extent : 
 And we likewife know, that the cavity of 
 almoft every tumor may be more efFecluai- 
 ly deftroyed by producing an adhefion of 
 its fides than by any other means. 
 
 Parts of the human body in a ftate of 
 inflammation very readily adhere to one 
 another. Indeed fo eafily do they do fo 
 that fome art is required to prevent the 
 adhefion of contiguous inflamed parts. By 
 attempting the cure of abfcefles and of en- 
 cyfted tumors, on principles analogous to 
 this, the fame phenomena were found to 
 happen ; for, after difcharging their con- 
 tents, it has been found, that cures are 
 commonly obtained with more eafe and 
 3 cer- 
 
43^ ^f i^^^ Hydrocele* Chap. VL 
 
 certainty by inducing a fufficient degree 
 of inflammation on their internal furfaces, 
 than by any other means. And in Hke 
 manner it is now known, that the hydro- 
 cele of the tunica vaginalis, may be treated 
 upon the fame principles, and with the 
 fame general effefts. 
 
 This is the mofl fimple idea that can be 
 given, of the prefent views of pracflitioners 
 in the treatment of this diforder ; and I 
 hope it will ferve to render their ideas re- 
 fpecling it fufficiently clear. 
 
 The intention, then, of every means now 
 in ufe for the radical cure of this fpecies of 
 the hydrocele, is, to induce fuch a degree 
 of inflammation on the parts, as may tend 
 to obliterate entirely the cavity of the tu- 
 nica vaginalis, by making it adhere firm- 
 ly to the tunica albuginea or furface of the 
 tefticle. 
 
 Some individuals, indeed, (till proceed 
 upon the fuppofition of a total deftruclion 
 of the fac being neceflary for a complete 
 cure. But the extenfive experience of 
 many of the beft employed furgeons makes 
 
Sed. III. Of the Hydrocele, 431 
 
 it appear very clear that this Is never ne- 
 ceffary. When the fac has become very 
 thick, and has been diftended to fuch a 
 degree as entirely to have loft its tone, re- 
 moving a fmall part of it fometimes proves 
 tifeful, by allowing the fcrotum to con- 
 tract more readily ; but in no other point 
 of view is it in any degree requifite. 
 
 We know well, that in this, as in every 
 fpecies of encyfted tumor, a cure may be, 
 and frequently is, obtained, by removing 
 the fac entirely ; for, the contiguous parts 
 from whence the facs have been difTed-ed, 
 adhere very readily together, fo as to de- 
 flroy effeclually the cavities in which the 
 matter was contained *. But we alfo know 
 that this is never neceffary, as the fame 
 end may be always obtained by much 
 more gentle means. 
 
 We fliall now proceed to the particular 
 
 confideration of the feveral means at pre- 
 
 '\ fent 
 
 * Mr Elfe aflertSj that in the method he recommends 
 of curing this fpecies of Hydrocele by cauftic, the tu- 
 nica vaginalis Houghs entirely off. 
 
43 « Of the Hydrocele. Chap. VI. 
 
 fent employed by different pracftitioners 
 for effeding a cure, and fliall treat with 
 mod minutenefs thofe which are now in 
 mofl: general ufe, Thefe are, excifion of 
 the tunica vaginalis ; the appHcation of 
 cauftic ; the ufe of a feton ; and a fimple 
 incifion of the fac. 
 
 By Mr Douglas it is recommended * to 
 deftroy the vaginal coat entirely ; and his 
 method of doing it, is, firft to difledl out 
 an oval piece of the fcrotum, which he 
 confiders as always necefTary ; and having 
 then laid the vaginal coat open, to cut it 
 away by different fnips of a pair of fciffars. 
 But if there is any practitioner who ftill 
 continues to prefer this excifion of the fac, 
 he will find that it may be more, eafily 
 diffedled away by the fcalpel than with 
 fciffars, and it is rarely neceffary to remove 
 any portion of the fcrotum. 
 
 The method of cure with cauftic is com- 
 monly defired to be condu(fted in the fol- 
 lowing manner : The fcrotum being iliaved, 
 a piece of common pafte- cauftic properly 
 
 fecured 
 
 * Loco citato. 
 
Sed. III. Of -the Hydrocele, 433 
 
 ■fecured wicri adhefive plafter is to be ap- 
 plied, of about the breadth of a finger, 
 the whole length of the tumor"; and if, 
 on removing the cauftic, it has not pene- 
 trated the tunica vaginalis, this is ordered 
 to be done v^ith a fcalpel, fo as to evacuate 
 the contents, lay bare the tefticle, and ad- 
 mit of proper drefTmgs *. 
 
 But Mr Elfe, one of the iateft writers in 
 favours of the method by cauftic, fays, 
 that there is no neceffity for fuch an ex- 
 tenfive application of cauftic as has been 
 recommended by authors : That an efchar 
 of the iize of a fhilling anfwers the pur- 
 pofe fufficiently : That this may be always 
 fully obtained by the application of cauftic 
 pafte of the fize of a {ixpence ; which he 
 direds to be laid upon the anterior and 
 under point of the fcrotum, and to be pro- 
 perly fecured by adhefive plafter in order 
 to prevent it from fpreading f . 
 
 Vol. I. E e The 
 
 * Douglas on the Hydrocele, p. 3. Pott, loc. clt^ 
 p. 155. 
 
 f Vid, An Effay on the cure of the Hydrocele of the 
 tunica vaeinalis teftis, 2d edition, p. 33- 
 
434 Of the Hydrocele, Chap. VI*, 
 
 The cauftic commonly produces all its 
 efFecfls in the fpace of five or fix hours, 
 and may then be removed. At this time 
 digellives, or an emollient poultice, mufl 
 be applied over the fcrotum; and the whole 
 properly fufpended w^ith a bandage. 
 
 Inflammation, we are told^ is foon in- 
 induced over the whole tunica vaginalis > 
 and the febrile fymptoms which fucceed, 
 are diredled to be kept moderate by blood- 
 letting, inje(5lions, &c. In a few days th© 
 efchar of the fcrotum feparates and comes 
 away ; and in a gradual manner, in the 
 courfe of four, live, or fix weeks, the whole 
 tunica vaginalis comes off, when the wound 
 immediately cicatrifes, and a complete cure 
 is obtained. 
 
 When the feton is to be ufed, the fol- 
 lowing is the method of applying it, as is 
 recommended by Mr Pott, who has wrote 
 a very ingenious treatife on this fubjedl : 
 He ufes a trocar ; a filver canula, five in- 
 ches in length, and of fuch a diameter as 
 to pafs eafily thro' the canula of the trocar; 
 and a probe, fix inches and a half long, 
 
 having 
 
Sed. HI. Of tJje Hydrocele^ ^ 435 
 
 having at one end a fine fteel trocar-pointj 
 and at the other an eye which carries a 
 cord of coarfe white fewing-filk, of fuch 
 a thicknefs as will pafs eafily through the 
 long canula. With the trocar, the infe- 
 rior and anterior point of the tumor is to 
 be pierced ; and as foon as the perforator 
 is withdrawn, and the water difcharged, 
 the feton canula is pafTed through that of 
 the trocar, till it reaches the upper part of 
 the tunica vaginalis, and can be felt in the 
 -very fuperior part of the fcrotum. This 
 being done, the probe armed with its feton 
 is to be conveyed through the latter ca- 
 nula, the vaginal coat and teguments to be 
 pierced by its point, and the feton to be 
 drawn through the canula till a fufficient 
 quantity is brought out at the upper ori- 
 fice, whenl)oth the canulas are to be with- 
 drawn, and the operation is finiihed. 
 
 About the end of the third day, the parts 
 begin to inflame; when fomentations, poul- 
 tices, a fufpenfory bandage, a temperate 
 regimen, and a lax belly, are ordered, to 
 keep the fymptoms moderate : As foon as 
 E e 3 the 
 
436 Of the Hydrocele, Cfiap. VL 
 
 the parts become eafy by the inflammation 
 lefTening, which is generally about the 
 tenth or twelfth day, the feton is begun to 
 be diminiflied, when fix or eight threads 
 lire withdrawn at every dreiling; the dref- 
 iings confiding of nothing more than -a 
 fuperiicial pledgit upon each orifice, and 
 a difcutient cerate, fuch as the feratum 
 iaturninum, to cover the fcrotum. 
 
 In ufing the feton, I fliould wifli to fol- 
 low the method here defcribed, in every 
 other point except in the mode of intro- 
 ducing it; an eaiier method of doing it 
 being now difcovered. In a former pub- 
 lication, I have defcribed the manner of 
 opening abfceffes by a feton ; and the di- 
 redlions then given, prove equally appli- 
 cable here. Let an opening be made, ei- 
 ther with a fcalpel or a lancet, in the fnpe- 
 rior part of the tumor, large enough to ad- 
 mit with eafe a cord of white fewing-filk 
 of a proper lize. The curved diredlor with 
 an eye at one end '^^ in which the cord is in- 
 ferted, is to be introduced at this opening ; 
 
 and 
 * Delineated in the Treatlfe on the Theory and 
 ir.aiKigement of Ulcers, &c. 
 
Seel. III. Of the Hydrvctk. 437 
 
 and its farther extremity being carried 
 down to the mofl depending part of the 
 tumor, an opening is there to be made of 
 about half an inch or ib in length, by cur- 
 ting upon the end of the diretflor with a 
 fcalpel. The diredlor being now drawn 
 down till a fufficient quantity of (ilk is lefc 
 hanging out below, the operation is then 
 finifhed. In every other refpecl the ma~ 
 nagement of the feton ought to be the 
 fame with the method we have defcribed 
 from Mr Pott. 
 
 By making the firft opening in the fupe- 
 rior part of the tumor, the inftrument con- 
 du(5ling the feton is more ealily introduced 
 to the farther extremity of the fwelling, 
 than when the firft opening is made below \ 
 for in this cafe, the tumor remains dif- 
 tended to the laft : Whereas, when opened 
 below, the water rufhes out immediately ; 
 and the vaginal coat collapfes fo much 
 about the tefticle, that I have feen a good 
 deal of difficulty in 2;ettin? the inftrument- 
 infinuated between them, by which I have 
 been feniible of the teflis being coniider- 
 ably injured. 
 
 E e 3 Before 
 
438 Of the Hydrocele, Chap. VI. 
 
 Before entering farther into the confi- 
 deration of this method of cure by the fe- 
 ton, we fhall proceed to defcribe the ope- 
 ration far a radical cure by incifion. 
 
 The patient being placed upon a table 
 of a convenient height, and being properly 
 fecured by two affiftants, with the fcrotum 
 lying nearly upon the edge of the table, 
 the operator with one hand fiiould grafp 
 the tumor fo as to hold it firm and make 
 it fomewhat tenfe on its anterior part ; and 
 with a common round-edged fcalpel in the 
 other, he fhould now divide the external 
 teguments by one continued incifion from 
 the fuperior extremity of the tumor all 
 along its anterior furface down to the moil 
 depending point of the fwelling. 
 
 By this means, as the divided fcrotum 
 retrads a little, the tunica vaginalis is laid 
 perfe(5lly bare, for the breadth of about half 
 an inch from one extremity to the other. 
 An opening is now to be made with a lan- 
 cet into the vaginal coat, juft at its upper 
 extremity where the firft incifion com- 
 rnenced. This opening fhould be of fuch 
 
Sc(ft. IIL Of the Hydrocele, 439 
 
 a fize as to receive the finger of the operator ; 
 which being inferted, the probe- pointed 
 biftoury is to be condu(5led upon it, and by 
 means of it the fac is to be divided to the 
 very bottom, all along the courfe of the 
 jfirft inciiion. By the previous divifion of 
 the ikin with the fcalpel inftead^^of the bi- 
 floury, the operation is done with much 
 more accuracy, and with lefs pain ; for ths 
 fcalpel from its convexity admits of a much 
 liner edge than an inftrument of any other 
 form is capable of receiving, and hence it 
 cuts with more eafe. 
 
 By making the firft opening in the up- 
 per end of the fac, much trouble and in- 
 convenience is prevented, which, making 
 the firft orifice below, is fure to occafion : 
 For, as we have before remarked, when 
 the tumor is firft opened below, the wa- 
 ter is inftantly evacuated ; and as this 
 produces an immediate collapfe of the tu- 
 nica vaginalis, the paffage through it is 
 not afterwards ealily difcovered. Where- 
 as, by making the firft opening above, as 
 the water is thereby evacuated gradually 
 E e 4 ^s 
 
44^ Of the Hydrocele, Chap. VI 
 
 as the exciiion is extended downwards, 
 the vaginal coat continues diftended to 
 the bottom till the incifion is completely 
 finifhed. 
 
 We have not thought it neceffary to fay 
 any thing here of the probe- pointed fcif- 
 fars, an infirument which fame time ago 
 was very generally employed in this ope- 
 ration : For wherever the knife can with 
 propriety be ufed, no furgeonof thefe times 
 will hefitate in preferring it. 
 '• We ha.ve directed the incifion into the 
 vaginal coat to be carried from one extre- 
 mity of the tumor to the other. Many 
 furgeons, with a view to fave fome pain 
 to the patient, advife the incifion both of 
 the fcrotum and tunica vaginalis to be on- 
 ly two-thirds of the length of the tumor. 
 But the difference of pain thus produced 
 is very little ; being indeed nothing when 
 compared with the uncertainty of a radi- 
 cal cure not being obtained by it. AVhen 
 the incifion is carried the whole length of 
 the tumor it is rarely found to fail j and 
 I have known fundry inftances of theft 
 
 partia'I 
 
Sedl. III. Of the Hydrocele, 441 
 
 partial openings being followed with a re-? 
 turn of the difeafe *. 
 
 The incifion being completed in the 
 manner we have diredled, the tefticle co- 
 vered with its tunica albuginea comes into 
 view. Sometimes the teflis protrudes from 
 the wound altogether ; in which cafe it 
 fhould be replaced with great caution, and 
 ought by all means to be covered as quick- 
 ly as pofTible from the external air ; and 
 provided none of the tunica vaginalis is to 
 be removed, this may be always done im- 
 mediately by finifhing the drefling dire<5l- 
 ly on the fac being opened. 
 
 When the fac is not much thickened, 
 there is no neceffity for removing any 
 part of it ; but when it is difccvered to be 
 otherwife ; to be thick and very hard ; the 
 removal of a portion of it on each fide of 
 the incifion, makes the cure of the remain- 
 ing fore more eafy and expeditious. As 
 in this hardened flate, the fac generally 
 feparates with great eafe from the fur- 
 rounding 
 
 * Mr Pott is clearly of this opinion. Loc> cit- 
 p, 163. 
 
44^ Of the Hydrocele* Chap. VI. 
 
 rounding teguments, any quantity of it 
 may be eafily taken away with the fcalpel 
 without the lead danger of wounding the 
 fcrotum. Some writers indeed advife part 
 of the fcrotum itfelf to be cut away on 
 every occafion*; but even in the moft en- 
 larged cafe of hydrocele I ever met with, 
 no necefTity ever appeard for removing 
 any part of it. 
 
 On examining the teflicle after the di^ 
 vifion of the vaginal coat, it is generally 
 found to be of a foft texture, and of a 
 more pale complexion than in a healthy 
 ftate : On fome occafions it is conlider- 
 ably enlarged ; and on others, I have ittw 
 it reduced to a very fmall fize, confifting 
 of the tunica albuginea almoft quite emp- 
 ty. As the cure of the fore however ad- 
 vances, the tefticle in a gradual manner 
 commonly regains its ufual bulk ; of this 
 I have feen different inftances, and a very 
 remarkable cafe of the fame kind is re- 
 corded by Douglas f . 
 
 *Vide Douglas on the Hydrocele, 136. 
 I i(jf. cit, p. 194, Cafe U. 
 
Sedl. III. Of the Hydrocele. 44^ 
 
 We have hitherto fuppofed that the dif- 
 order is confined to one fide of the fcro- 
 turn ; but now and then, as we have elfe- 
 where remarked, a double hydrocele is 
 met with. The ordinary pracflice in fuch 
 a cafe, is, to do the operation twice in all its 
 parts, both in the fcrotum j^nd tunica va- 
 ginalis ; to lay each colledion open from 
 top to bottom, by a double incifion. Some- 
 times both operations are done at the fame 
 time ; but in general practitioners are 
 afraid of too much inflammation being 
 thus induced, fo that one is commonly aK 
 lowed to heal before the other is attempted. 
 In this manner the patient is expofed to 
 delay, uncertainty, and to the hazard of 
 two complete operations. 
 
 It may be done, however, in a much ea~ 
 lier manner, with much It^z pain, and in 
 lefs time, than in the ordinary method. 
 
 After finifhing the operation on one fide, 
 by making an opening into the vaginal 
 coat of the oppofite tefticle at its upper 
 extremity through the feptum fcrotiy and 
 continuing the incifion down to the bot- 
 %ova of the tumor, the cyft is thus equally 
 
 well 
 
444 ^f ^^^ Hydrocele, Chap. VT. 
 
 well laid open, the water is as completely 
 evacuated, and the patient is liable to as 
 little hazard of a return of the diforder, as 
 if the operation had been done in the ufual 
 manner. 
 
 From the account we gave of the ana- 
 tomy of the fcrotum, no danger, it is evi- 
 dent, can occur from any divifion of the 
 feptum, which we have fliown to be en- 
 tirely compofed of cellular fubftance ; and 
 in fadl I have twice had an opportunity of 
 performing this operation in the manner 
 here dire(fl:ed upon a double hydrocele, 
 and in both inftances with mofl complete 
 fuccefs. 
 
 Whether the hydrocele be double or 
 confined to one tefticle, as foon as the wa- 
 ter is all evacuated, and any part of the 
 vaginal coat removed that may be necef- 
 fary, the wound ought then to be drefTed ; 
 and on this, it may be obferved, much of 
 the fuccefs to be expedled from the opera- 
 tion depends. 
 
 If the vaginal coat be juft. wrapped a- 
 bout the tefticle without the interpolition 
 
 of 
 
S^6l. III. Of the Mydrocek, 445 
 
 of any kind of dreffing, partial adhefions 
 are apt to occur, before a degree of in- 
 flammation is produced fufficient for ren- 
 dering the cure complete. By this means 
 cavities are left, which either fill with pu8 
 during the progrefs of the cure, or after- 
 wards afford an opportunity for colledtions 
 of water, and thus occafion a return of the 
 diforderj different inflances of which I 
 have met with. 
 
 And again, a defire for (lufEng the cavity 
 of the. fore too much with dreffings has 
 alfo .been a frequent caufe of mifchief. By 
 their rubbing or prefling too much upon 
 the furface of the tunica albuginea, a part 
 which nature never intended to be much 
 expofed, fuch a degree of inflammation is 
 fometimes induced as to be produdlive of 
 much pain, inflammation, and fever: But 
 it is commonly the fault of the operator 
 when this is the cafe ; for in a found heal- 
 thy conftitution, it feldom happens thac 
 either of the occurrences we have men- 
 tioned take place when the drefTmgs are 
 properly managed. 
 
 3 , The 
 
44^ Of the Hydrocele* Chap. VI. 
 
 The method I have uniformly found to 
 fucceed, is this : The tefticle, if it has 
 puflied forwards, as it fomecimes does, out 
 of the fcrotum entirely, being cautioufly 
 replaced, a piece of fofc lint fhould be in- 
 ferted between it and the divided vaginal 
 coat, firft on one fide of the divided fac, 
 and then on the other, reaching from the 
 faperior part of the tumor to the mod de- 
 pending point of it. One end of each 
 piece of lint ought to be left out of the 
 fore, to fold over the edges of the wound ; 
 and the other ought to be gently pufhed 
 in between the teftis and the vaginal coat, 
 about half-way between the external inci- 
 iion and the bottom of the fac : If lefs is 
 inferted, it does not with certainty anfwer 
 the purpofe ; and I have commonly found 
 that a fingle ply of fine lint may be intro- 
 duced this length without any difficulty, 
 and experience fhows it to be fufficient. A 
 comprefs of foft linen being now applied, 
 over the tumor, the whole fliould be pro- 
 perly fafpended witha bandage; and for this 
 purpofe, either the T-bandage, or the com- 
 mon 
 
Seel. in. Of the HydrocelL 447 
 
 mon fufpenfory bag, may be employed. 
 The patient is now to be carried to bed ; 
 an anodyne fhould be prefcribed ; and he 
 ought to be enjoined to remain as much 
 in the fame pofture as poiTible, for much 
 motion in this ftate of the fore certainly 
 does mifchief. 
 
 The intention of this operation being to 
 induce a moderate degree of inflammation 
 in the pares chiefly affedted, viz. the tu- 
 nica vaginalis and tunica albuginea, if the 
 pain, inflammation, and fwelling, which 
 in fome degree always fucceed to the ope* 
 ration, do not run to a great height, no- 
 thing is to be done for the iirfl tvv'o or three 
 days after the operation : But, when thefc 
 fymptoms become violent, and efpecially 
 when any conliderable degree of fever is 
 induced, it mufl then be the buflnefs of 
 art to prevent their going too far. The 
 remedies to be ufed for this purpofe, are, 
 blood-letting, according to the flrength of 
 the patient ; gentle laxatives, fo as to pre- 
 ferve an eafy ftate of the bowels ; a low 
 cooling diet j and warm emollient poul- 
 3 tices 
 
44S Of the Hydrocele. Chap.VL 
 
 tices and fomentations to the part, in order 
 to forward a plentiful fuppuration, which 
 commonly tends to moderate every bad 
 fymptom more effectually than any othe^ 
 remedy. 
 
 By thefe means the inflammation may 
 in almod every inflance be kept within 
 proper bounds : From all the experience* 
 indeed, which I have had in this diforder, 
 1 might fay that it may be done in every 
 inflance; for I never yet faw any thing to 
 the contrary, where the operation was pro- 
 perly performed, in a found healthy con- 
 ftitution. 
 
 When, again, the pain, inflammation* 
 and tumefaction of the parts, do not come 
 to a great height, the cataplafms and fo- 
 mentations need never be employed before 
 the fourth day : About this time, by fo- 
 menting the parts, and applying a large 
 emollient poultice over the whole, the ex- 
 ternal drefGngs are commonly eafily re- 
 moved about the fifth or fixth day. At 
 this time, on taking them away, the edges 
 of the fore are obferved to be hard, and 
 confiderably fwelled ; and the matter dif- 
 
 charged 
 
Sedl.IlI. Of the Hydrocele, 449 
 
 charged is thin and difcoloured: If the 
 lint inferred between the teftis and the va-* 
 ginal coat can be eafily taken out, it may 
 at this time be removed ; but in general, 
 it does not come away with freedom till 
 the third or fourth drefling, when the 
 fwelling of the parts is fomewhat dimi-» 
 niHied. The fore ought to be drelTed once 
 every day or two, according to the quan-* 
 tity of matter produced ; and the poul^ 
 tices fliould be continued till a plentiful 
 fuppuration is eftablilhed. 
 
 In twelve or fourteen days from the 
 operation, the fuppuration is in general 
 very freely formed ; and the fwelling of 
 the parts is now fo much reduced as to 
 give the whole a fine healing appearance: 
 The only drefTmg neceffary in this flate of 
 the fore, is a little fofc lint, covered with 
 a pledgit of any emollient ointment. The 
 fwelling of the fcrotum now gradually 
 fubfides; and the fore continuing to lefferi 
 daily, a complete cure is commonly obtain-^ 
 ed in the fpace of four, five, or fix weeks, 
 according to the fize of the woynd and 
 other circumftances. 
 
 VPL, I. F f Ha- 
 
45^ QT/Z^J Hydrocele. Chap. VI. 
 
 Having thus given an account of the 
 manner of performing every operation at 
 prefen^ in ufe for the radical cure of the 
 hydrocele, we Ihall now make a few ob- 
 fervations on the comparative advantages 
 of the three laft, viz. thecauftic, feton, and 
 the fimple inciiion ; thefe being almoft the 
 only means now pracflifed for the removal 
 of this diforder. From the teflimony of 
 many refpedlable authors concerning the 
 efficacy of each of thefe, there is no rea- 
 fon to doubt, but that colledlions of this 
 kind may in general be cured by any of 
 them. That the cauftic, when properly 
 managed, will feldom fail of producing a 
 cure, we have every reafon to believe ; and 
 the fame may be fafely afferted both of 
 the feton and the fimple inciiion. But, it 
 commonly happens, that a pradtitioner,. 
 from being prejudiced in favours of a par- 
 ticular method, continues to pradlife that 
 mode and no other; and finding it in ge- 
 neral fucceed, he by degrees comes to per- 
 iuade himfelf, that other methods of cure 
 ■wkh^whiGh he has not had fuch opportu- 
 nities 
 
Sed.lII. Of the Hydrocele, 451 
 
 iiities of becoming acquainted, are liable 
 to objections, which thofewho have prac- 
 tifed them do not find to be the cafe. 
 
 I attended the hofpitals in London abouc 
 the time that Mr Pott's publication on the 
 Seton, and Mr Elfe's Treatife on the Cure 
 of the Hydrocele by Cauftic, were pub- 
 lifhed ; when of courfe the various means 
 of curing the diforder were frequently the 
 fubjedl of medical converfation. I was 
 thereby induced to pay particular atten- 
 tion to the fubje6l ; and having the ad- 
 vantage of feeing the pra(5lice of different 
 hofpitals, and not being particularly biaf- 
 fed in favours of any one method, I was 
 thus furnilhed v>^ith an excellent opportu- 
 nity of forming an opinion : And the refulc 
 of all the obfervation 1 was either at that 
 time able to make, or fince that period, 
 both in the hofpital here, and in private 
 pradlice, is. That although all the three 
 modes of operating, by cauftic, the feton, 
 and limple incifion, are perhaps equally ca- 
 pable of producing a radical cure ; yet thac 
 of the three, the latter, viz, the limple in« 
 F f 2 ciliofj, 
 
^S^ Qf^^^^ Hydrocele, CKap. VL 
 
 ciiion, is liable to fewer objefflions, and' ef^ 
 fedls a cure both with lels trouble to the 
 operator, and with lefs riik to the patient : 
 and of the other two, the treatment by cau- 
 flic appears to me to be the moft eligible. 
 
 I have feen all the three methods produce 
 troublefome fymptoms^ fuch as great pain 
 and tenfion of the abdomen, inflammation, 
 and fever ; but from much obfervatlon, I 
 can without hefitation fay, that the fe- 
 ton is more frequently produdlive of thefc; 
 confequences than either of the others : 
 And we need not wonder at this being the 
 cafe ; for the cord which is here introdu- 
 ced, lying in clofe conta(5l with the body 
 of the teftis, mufl neceffariiy occafion a 
 confiderable and continued irritation, as 
 long as it remains applied to it. 
 
 Thefeton is likewife attended with other 
 inconveniences, to which neither of the 
 others, when properly managed, are liable. 
 When the inflammation which fuccecds 
 to the introdudtion of the cord runs very 
 high, as it frequently does, it commonly 
 !^erminates in fuch a plentiful fuppuration^ 
 Ehat th^ matter produced by ic cannot be 
 
 readily 
 
Sea. III. of the Hydrocele, 453 
 
 readily difcharged at the opening made for 
 the feton: In confequence of this, it infi- 
 nuates itfelf into the neighbouring parts; 
 and different abfeeffes are accordingly 
 formed, which muft all be difcharged by 
 as many opemngs. Even when the opera- 
 tion has been done with much nicety and 
 attention, I have feen it terminate in this 
 manner. 
 
 Another obje<5lion to this operation, 
 -which 1 think of importance, is this : k 
 does not admit of a free examination, ei- 
 ther of the flate of the tefticle, or of the 
 iluid contained in the fac. I knov*-, that 
 in a fimple uncomplicated hydrocele, there 
 is no reafon whatever for esamining the 
 tefticle ; nor would we think of removing 
 it either on account of a mere enlargement 
 or diminution of its fize, provided it be 
 not other wife difeafed. But we know well 
 that cafes do fometimes occur, which elude 
 •the utmoftikill and penetration of thefur- 
 'geon ; no diagnoftic fymptoms with which 
 ^we are yet acquainted -being fufficient to 
 diredl us with abfolute certainty. 
 
 -!rhe mod experienced pradlitioner muft 
 F f 3 be 
 
454 Of the Hydrocele » Chap. VI 
 
 be fenfible, that at times he has been mif- 
 taken in his opinion refpedling the nature 
 offuch tumors ; a realfarcocele, orfcirrhous 
 tefticle, attended with fome efFufion of a 
 iluid, being now and then miflaken for a 
 pure unmixed hydrocele j and, vice njerfay 
 a nmple uncomplicated cafe of hydrocele 
 has been frequently mifiaken for, and 
 treated as, a fcirrhous tefticle. Such oc- 
 currences every pra6litioner mufl have 
 met with : iVnd among other writers who 
 confcfs their having been deceived in fuch 
 cafes, a very candid acknowledgment of 
 this kind is made by Mr Pott*; and Mr 
 Elfe takes notice of a iimilar occurrence in 
 ■which he was concerned f , 
 
 I 
 
 * Treatlfe on the Hydrocele, p. 2SS. In this cafe, 
 which from every circumitance had been confidered 
 as a Sarcocele, the teflis, after being removed, was 
 found to be perfectly found ; the difeafe being a real 
 Hydrocele of the tunica vaginahs. 
 
 There being even a pojjibility only of fuch an oc- 
 currence with fuch an attentive obferver as Mr Pott, 
 ought to ferve as a mod convincing argument with 
 praftitioners in general, of the neceffity of proceeding 
 with the utmoft- caution in all fuch cafes where there. 
 is the leaft caufe for doubt, 
 f LoQ. cit. p. 4. 
 
Sea. in. Of the Hydrocele, 45 5 
 
 I have myfelf been concerned in difFer- 
 enc cafes, where the moft experienced fur- 
 geons were at a lofs to determine the real 
 nature of the diforder; that is, whether the 
 fwelhng in the fcrotnm was a fimple hy- 
 drocele of the vaginal coat, or an etTuiion 
 of a fluid into that bag produced by a 
 fcirrboils tcfticle. In all fuch cafes where 
 any doubt occurs, the furgeon ought to 
 proceed as if the tumor was a real hydro- 
 cele. If, on laying open the fwelhng, the 
 tefticie fhould be found difeafed, that is, 
 if it fhould be in fuch a ftate as to require 
 extirpation, it ought to be removed imme- 
 diately ; and on the contrary, if it fiiould 
 appear to be perfedlly found, the cafe fliould 
 undoubtedly be treated altogether as a 
 fimple hydrocele. 
 
 In feveral inftances of this kind, where, 
 by different practitioners, a mere col- 
 lection of water was expedled without 
 any other afFedlion, the tefticle has been 
 found to be fo mnch difeafed with a real 
 farcocele, as to render extirpation highly 
 proper. No.w, if in fuch circumftances 
 F f 4 a 
 
45^ O/*//?^ Hydrocele, Chap.VL 
 
 a cure had been attempted by the feton, 
 the tellicle would have been allowed to 
 remain expofed to the irritation produced 
 by the cord, which in all probability 
 "would have induced very troublefome and 
 even alarming fymptoms ; for we know 
 that every fymptom of a fcirrhous or can^ 
 cerous tumor is uniformly rendered worfe 
 by irritation. 
 
 It has been alleged, that the real flate of 
 the teflis may be always known, by draw- 
 ing the water off from the tunica vaginalis 
 by a trocar ; and this has accordingly been 
 recommended as a previous ftep to the in- 
 irodu(5lion of the feton, with a view to 
 afcertain the fituation of the tefticle. But 
 it often happens, even after all the water is 
 drawn off, that the thicknefs produced by 
 the^ vaginal coat and fcrotum, collapfing in 
 large folds about the teilis, precludes ef- 
 fecSlually every accurate examination of this 
 kind. 
 
 "We obferved above too, that when the 
 feton is ufed, the contents of the vaginal 
 coat cannot be properly afcertained. It 
 
 fre- 
 
Se<^.IIL Of the HydiDcek. 457 
 
 frequently happens, that the water of a 
 hydrocele is contained in a number of hy- 
 datids; a circumftance which cannot be 
 difcovered previous to the opening of the 
 tumor: And -as it will be readily admit- 
 ted that the method of cure by feton is ill 
 fuited for evacuating hydatids, this of it- 
 felf is a very material objecftion to the prac- 
 tice. So that, upon the whole, although 
 the feton in every other refpecl fhould be 
 equally eligible with the fimple incifion, 
 which for the reafons formerly given I think 
 it is not, yet the two lad objedlions we have 
 adduced againft it are fufEcient reafons for 
 fetting it entirely afide. 
 
 With refpe6l to the mode of treatment 
 by cauftic, I have only to obferve, in addi- 
 tion to what was already faid upon this 
 fubjedl, that where patients are naturally 
 timidj and do not incline to fubmit to the 
 operation by the knife, this will in general 
 be preferable. 
 
 But the treatment by cauftic is liable to 
 one very material objedlion, which never 
 attends the cure by incifion, viz. that of 
 being produdive of finufes, and collec- 
 tions 
 
458 Of the Hydrocele. Chap.VL 
 
 tions of matter, in tl^e fcrotum and cellu- 
 lar fubftance Cf>nned:ing that bag to the 
 tunica vaginalis. One inftance of this I 
 have feen, where it was neceffary to eva- 
 cuate different collections of matter by 
 different openings; and a remarkable cafe 
 of the fame kind is related by Douglas, 
 where an exrenfive incifion was neceffary 
 for removing the colledions which occurr- 
 red *. For this reafon, therefore, and as 
 the mode by incifion brings the ftate of 
 the teftlcle more evidently into view; and 
 efpecially as, from all the experience 1 
 have had of the two different methods of 
 cure, that by incifion feems in general to 
 be producftive of the lead troublefome 
 fymptoms, 1 am clear that it ought to be 
 preferred. 
 
 In different publications, we read of 
 many dreadful fymptom.s induced by this 
 operation for the hydrocele; but the fame 
 objeclions have been adduced againft every 
 mode of operating hitherto propofed, and 
 the fame will flill be continued by fuch as 
 
 judge 
 
 * Loc. cit. p. 105. 
 
Sedl.lII. Of the Hydrocele. 459 
 
 judge from partial information. In old, 
 infirm, or difeafed conflitutions, this and 
 every other mode of operating will on 
 fome occafions be produclive of trouble- 
 fome and perhaps fatal confequences : On 
 the contrary, all the three methods of cure 
 of which we have been treating, viz. thofe 
 by cauflic, the feton, and fimpie inciiion, 
 will in general be found to anfwer the 
 purpofe very efFedtaally, of producing a 
 radical cure of the diforder. What I have 
 been here endeavouring to fhow, and what 
 the importance of the fubje(5l makes me 
 again repeat, is, that this end will com- 
 monly be obtained with more eafe both to 
 the operator and patient by the iimple in- 
 ciiion than by any other means. 
 
 In a matter of this kind no perfon ought 
 to form an opinion haflily. Nothing but 
 a variety of opportunities of putting the 
 different operations in practice, can enable 
 any pra6i:itioner to judge with propriety 
 of the merits of each. In the writings of 
 the late celebrated Mr Sharpe, we have a 
 v^vj remarkable inftance of this. In his 
 
 treatife 
 
£6o Of the Hydrocele. Chap. VI, 
 
 treatife on th^ Operations of Surgery*, he 
 fpeaks of the treatment of the hydrocele 
 by incifion as a very dangerous operation, 
 and thinks that it will probably be dif- 
 carded altogether. 
 
 At that time, it is evident, Mr Sharpe's 
 experience in this diforder had not been 
 faflicient for warranting fuch a decifive 
 opinion. It proved to be very contrary to 
 the direct experience of fome of our beft 
 furgeons ; and Mr Sharpe himfelf feems 
 afterwards to be convinced that his firft 
 ideas refpe(5ling this operation had been 
 very ill founded f . 
 
 I will not pofitively fay, that the expe- 
 rience of another pradlitioner will not 
 lead him to make a different conelufion 
 refpec^ing the fuccefs of thefe three modes 
 jef operating. Confequences which I have 
 not met with, may follow each of thefe 
 methods. My opinion is chiefly founded 
 on my own obfervation; and as the op- 
 portunities I have had of treating this dif- 
 order 
 
 * Tenth EditloA, Chap. IX. 
 
 •f Fuk Critical Inquiry, Firft Edition, p. 86, 
 
Sea. IV. Of the Hydrocele. 461 
 
 order, and of being concerned wicli others 
 in the management of ic, in all the variety 
 of ways we have mentioned, have been 
 frequent and ample, I have delivered ic 
 without referve or difficulty. 
 
 To thofe who are not thoroughly ac- 
 quainted with the importance of the fub- 
 jedt, it may perhaps appear that it has 
 been here treated with more minutenefs 
 than is necelTary ; but 1 know I will not be 
 conlidered as blameable in this particular 
 by pradlitioners of experience. 
 
 We now proceed to confider the third 
 fpecies of fcrotal hydrocele, viz. that va-^ 
 riety of the diforder in which the wa*- 
 ;er is colleded in the cavity of a hernial 
 fac, 
 
 SECTION IV. 
 
 Of the Hydrocele of a Hernial Sac. 
 
 IN every fpecies of hernia, when the parts 
 have been long protruded, a quantity 
 ©f a ferous fluid colleds in the bottom of 
 
 the 
 
492 Of the Hydrocele, Chap. VI* 
 
 the fac; and if any obftacle occurs to the 
 abforption of this, if the diforder is leated 
 in the fcrotum, we can eaiily conceive the 
 pollibility of the tumor augmenting to 
 fuch a lize as to afford all the ufual marks 
 of a hydrocele: and accordingly, on con- 
 fulting the various authors who have writ- 
 ten upon hernia and hydrocele, I find a 
 number of cafes enumerated, which fuffi- 
 ciently warrant the infertion of this as a 
 real, and perhaps not an unfrequent, variety 
 of the diforder. 
 
 It was well known to the ancients, that 
 a confiderable quantity of a fluid is fre- 
 quently contained in the fac of a hernia, 
 along with the parts protruded from the 
 abdomen; but Saviard feems to have been 
 the firu who entered into a particular con- 
 fideracion of this occurrence. Le Dran 
 relates different cafes of it : Heifter fpeaks 
 cf it under the title of Hydro-entreocele: 
 And the late Dr Monro defcribes it with 
 his ufual accuracy, and mentions a cafe of 
 this kind where fix pounds of water were 
 evacuated from the tumor by an opening 
 
 4 made 
 
Sea. IV. Of the Hydrocele, 463 
 
 made with the trocar *. A cafe of i: is 
 alfo related by Douglas f , and tv/o cafes 
 of a fimilar nature are mentioned by Mr 
 Pott J. 
 
 The water is in this diforder confined 
 in a cy ft "formed by a procefs of the peri- 
 tonaeum, and as it occupies nearly the fame 
 fituation in the fcrotum with the hydro- 
 cele of the tunica vaginalis, fo we cannot, 
 by the feel alone, on every occation, mark 
 the difference between them. For altho' 
 the tefticle in this fpecies of hydrocele is 
 commonly diftinguiihed more evidently 
 at the lower and pofterior part of the fwei- 
 ling than in the hydrocele of the vaginal 
 coat, yet the difference in this particular 
 between the two difeafes is not always fo 
 evident as to prove a fujEcient mark of 
 diftin(51:ion. 
 
 When a portion of gut and other parts 
 forming the hernia are down, the fulnefs 
 they produce along the fpermatic cord, 
 ferves in fome meafure to diftinguifh the 
 
 diforder 
 
 * Monro's Works, p. 579. f Loc. cit, p. 18:. 
 X Treatife on the Hydrocele, p. 21, 
 
464 Of the Hydrocek, Chap. VI, 
 
 diforder from a fimple hydrocele. And 
 when, along with this and other fympcoms 
 of hernia, we evidently difcover in the 
 tumor of the fcrotum a fluduation of a 
 fluid, if this fluid can by prefTure be made 
 to difappear either entirely or in part, the 
 nature of the diforder is thus rendered 
 obvious. 
 
 This fpecies of hydrocele may occur as 
 readily in the hernia congenita as in any 
 other variety of rupture, and in that 
 event, the water muft for certain be con- 
 tained in the fame fac both with the tef- 
 ticle and protruded inteftines. Indeed, as 
 all the fluid naturally fecreted for keeping 
 the furface of the different abdominal 
 vifcera moift, mufl in the cafe of a conge- 
 nital rupture fall into the hernial fac, we 
 would be induced to fuppofe that almofb 
 every cafe of this kind of hernia ought to 
 be complicated with the diforder we arc 
 now defcribing. The two cafes of this 
 fpecies of hydrocele related by Mr Pott, we 
 ftnd to have been connected with a hernia 
 congenita j and I havemyfelf feen two in- 
 4 ftances 
 
Sea. IV. Of the Hydrocele. 465 
 
 fiances of thp fame kind. But whether 
 this commonly happens or not, farther 
 obfervation will clifcover. 
 
 Whatever fpecies of hernia this kind of 
 hydrocele may be connecfled with, if the 
 water can by prefTure be made to pafs into 
 the abdomen, this will always prove a cer- 
 tain charadlerifl-ic of the difeafe ; for in 
 no other fpecies of encyflcd hydrocele is 
 it pofTible to make the water difappear by 
 preifure. It may happen, however, in this 
 kind of hydrocele, that this diftinguifhing: 
 fymptom of the difeafe does not exifl ; 
 for if by the prefmre of a trufs, or from, 
 any other caufe, an adhefion is produced 
 in the groin between the fides of the her- 
 nial fac, if the under part of the fac con- 
 tinues open with water colleifled in it, 
 the tumor which it occafions will afford 
 all the ufual appearances of a hydrocele, 
 while no part of its contents can be made 
 to pafs into the abdomen by prefTure : A 
 cafe of this kind we find related by Le 
 Dran, where the neck of the hernial fac 
 
 Vol. I. G g was 
 
466 of the Hydrocele, Chap. VL 
 
 wasfhut completely, and a hydrocele form- 
 ed in the under part of it. 
 
 In fuch a cafe, the only means of diftinc- 
 tion will be, an acquaintance with the 
 previous hiftory of the diforder. When- 
 ever in an ambigious cafe of this kind it 
 is found, that, before the water began to 
 collecfl in the fcrotum, the patient had been 
 liable to a hernia of the fame fide, this cir- 
 cumrtance alone will tend much to deter- 
 mine the nature of the difeafe. But even 
 although a miflake (hould occur here, and 
 although this fpecies of hydrocele fliould 
 be confidered by a praditioner as a fimple 
 hydrocele of the tunica vaginalis, nothing 
 bad could enfue from it ; for the treat- 
 ment adapted to one fpecies of the difeafe, 
 would apply with nearly equal propriety 
 to the other. 
 
 But when the protruded parts ftill re- 
 main down, unlefs the operation for the 
 bubonocele is at the fame time fubmitted 
 to, no other operation fliould be attempted 
 than that of difcharging the water by a 
 pundure with a fnaall trocar, when theiize 
 
 o£ 
 
Sedl. IV. Of the Hydrocele, 467 
 
 of the tumor renders fuch a ftep neceflary. 
 For unlefs it was intended to perform the 
 operation for the hernia at the fame time, 
 much mifchief might enfae from expofing 
 the bowels to the external air, by laying 
 the tumor open for a radical cure of the 
 hydrocele. 
 
 Whenever in this fpecies of hydrocele ic 
 is refolved to have recourfe to the radical 
 cure, the fimple incifion ought unqueftion-^ 
 ably to be employed ; as from the riik of 
 injuring the bowels or other parts pro^ 
 truded from the abdomen, neither the fe- 
 ton nor cauftic are here admiilible. Indeed 
 this confideration of itfelf affords a very 
 ftrong argument in favour of the method 
 of treating the hydrocele in every inftance 
 by incifion, which lays all the parts concern-^ 
 ed in the diforder open to view: The very 
 pofTibility of a patient being killed by a feton 
 pafTmg thro' a portion of inteftine contains 
 ed in a hydrocele, is a weighty objedlion 
 againft the feton being ever ufed; and every 
 praditioner mufl acknowledge, that whea 
 the fpermatic procefs along the groin is 
 G g 2 muA 
 
46S CftbsHjdrvcde^ Chap. VI. 
 
 much dillended, and when the vaginal 
 coat of the xc^is is much thickened, fuch 
 nncertainty often occurs as to render it 
 impofSbie for the mod fkilful furgeons to 
 detennine with precilion what the contents 
 of fuch fwellings really are. In the two 
 inllances above alluded to, of a hydrocele 
 connecled with a congenital hernia* and 
 which 1 met with fome years ago, there 
 had not been previoufly in either of them 
 any cauie to fufpecl the real nature of the 
 cafe. They were both by ikilful practi- 
 tioners taken to be coliecHons of water in 
 the tonica vaginalis without any compli- 
 cation whatever; and in each of them, on 
 the tumor being laid open, together with 
 water in ccmtacl with the teflicle, a piece 
 of intsiiine was found protruded into the 
 upper part of the fcrotum : In one of the 
 cafes, too, a finall portion of omentum ac- 
 companied the gut. 
 
 In this iaft, it was propofed, 2t aconful- 
 tation of diSerent fui^eons, to employ the 
 feton. For fome reafon or other, this was 
 feasnately rejecied ; for, on laying the tu- 
 mor 
 
Secl.V. Of the Hydrocele, 469 
 
 mor open by incifioait evidently appeared, 
 that if a cord had been introduced, it muil 
 in all probability have paiTed through the 
 protruded gut. The mere poflibility, there- 
 fore, of fuch an occurrence, I would con- 
 iider as a very material objection to the 
 method of treating any cafe cf encyfted 
 hydrocele by the feton. 
 
 SECTION V. 
 
 Of the Anafarcaus Hydrocele af the Spermatic Qrd, 
 
 N the anatomical defcription we. gave of 
 thefe parts, it was obferved, that, foon 
 after the defcent of the teftis, the palTage 
 along the fpermatic procefs of the perito- 
 neum is completely obliterated, by the 
 Aides of the paflage adhering to one ano- 
 ther through the intervention of cellular 
 fubflance. 
 
 By external prefTure, and perhaps from 
 other caufes, this adhefion of the fides of 
 the peritonsEal procefs in general is very 
 '£rm in that part of it which palles along 
 the groin ; but the fuperior and more in- 
 G g ^ . ternal 
 
470 Of the Hydvocele. Chilf). VL 
 
 ternal part of the procefs, is not only mors 
 loofe in. itfelf, but is connecfled with and 
 enveloped in a very loofe cellular fub- 
 ftancc. 
 
 From this cellular ftruclure of thefe 
 parts we might a priori fuppofe them to be 
 liable to oedematous fwellings, which other 
 parts of the body of a flmilar ftructure arc 
 frequently attacked with: And according- 
 ly, we find this procefs of the peritonseum 
 liable to partake of every anafarcous fwel* 
 ling with which the reft of the body is 
 attacked : it fometimes accompanies af- 
 cites ; and it now and then appears as a 
 local diforder, without being combined 
 •with either of thefe* 
 
 The caufes of this diforder in general 
 are, obftru(5lions produced in the lym- 
 phatics of the pare, by fcirrhous afFedlions 
 of the liver, fpleen, and other abdominal 
 vifcera : I have likewife known it induced 
 by the prelTure of a trufs applied for the 
 cure of a hernia*. 
 
 Wheii 
 
 * An inflance of this kind is alfo mentioned hy 
 i^puglas. Treatifc on the H^drocelso 
 
Se6:. V. Of the Hydrocele, 471 
 
 When a fwelling of this kindis connec- 
 ted with a general anafarcous affection, 
 the nature x)f the diforder is fo diftin^lly 
 marked as to render a particular defcrip- 
 tion of it unnecefTary. When it oc- 
 curs as a local difeafe its appearances are 
 thefe : A colourlefs tumor in the courfe of 
 the fpermatic cord.; foft and inelaftic to 
 the feel, and not attended with tiu6luation. 
 In an ^red poftur^, it is of an oblong fi- 
 gure.; but in a recumbent pofture of the 
 body, it becomes more flat, and fomewhat 
 round. It does not commonly occupy more 
 than the ufual flretch of the cord along 
 the groin ; but on fome occafions, it ex- 
 tends down the length of the teflicle, and 
 even ftretches the fcrotum to an enormous 
 fize*. By preffure the fwelling can be al- 
 ways made to recede, if not entirely, at 
 lead in great part, into the cavity of the 
 abdomen ; but it inftantly returns to oc- 
 G g 4 cupy 
 
 * A remarkable inftance of this is related by Mr 
 Pott, who from a fwelling of this kind difcharged 
 eleven Englifh pints at once. Treat'ife on the Hydra-^ 
 -^sle^ Cafe X. 
 
472 Of the Hydrocde. Chap. VI. 
 
 cupy its former fituation on the preflure 
 being withdrawn. 
 
 When a tumor of this kind depends up- 
 on a general anafarcous fweliing of the 
 body, unlefs the caufe which gave rife to 
 the original difeafe of the conflitution be 
 removed, it would be a vain attempt to en- 
 deavour to cure this particular fymptom : 
 and it commonly Jiappens, that thefe fwel- 
 lings in the groin n^hich occur in the ana- 
 farca difappear, when the difeafe of the 
 iyftem at large is carried off. 
 - But when a fweliing of this nature oc- 
 curs as an original diforder; produced per- 
 haps by fome local caufe ; a local remedy 
 is then the only means neceffary to be em- 
 ployed. In fuch a cafe, as we have not the 
 general bad habit of body to encounter, 
 •which commonly occurs incafes of fcrotal 
 anafarca, we need not be fo much afraid 
 of making a free large incifion into the 
 tumor ; and accordingly all that is necef- 
 fary to be done here, is this: As foon as the 
 fweliing has acquired fuch a iize as to be- 
 come inconvenient, an incifion fliould be 
 
 made 
 
Sedl. V. Cj the Hydrocele » 
 
 ■/J 
 
 made with a fcalpel from one end of it to 
 the other, taking care to go fo deep as ef- 
 fecfiually to evacuate all the vv-ater contain- 
 ed in the cells of the part ; and as the wa- 
 ter is now and then found to have acqui- 
 red a vifcid cpnfiftence, this circumftance 
 renders a deep incifion more necelTary than 
 it otherwife would be. 
 
 The contents of the fwelling being all 
 removed, fome fcft lint fliould be inferted 
 between the lips of the fore, which mufl 
 afterwards be treated in every refpect as a 
 iimple wound from any other caufe ; by 
 poultices and fomentations, if much pain 
 and a fcanty fuppuration render thefe re- 
 medies neceiTary ; and by a due attention 
 to dreffing fo as to induce the formation of 
 firm granulations from the bottom. 
 
 SECTION VI. 
 Of the Encyfted Hydrocek of the Spermatic Cord. 
 
 'TT'HE furrounding fubflance of the fper- 
 matic cord being altogether cellular, 
 
 the 
 
^4 Of the Hydrocele, Chap. VI. 
 
 the formation of encyfted tumors, we may 
 
 conclude, ought here to be as frequent as 
 in other parts of the body ; and accord- 
 ingly we find in fome inflances, that water, 
 inftead of difFuiino: itfelf over the whole 
 
 O 
 
 fpermatic procefs, is coUedled in one or 
 more diftincl cells or cyfts. 
 
 This kind of hydrocele being on its firft 
 appearance very fmall, gives little or no 
 trouble, and is therefore feldom much no- 
 ticed till it has acquired a larger fize. On 
 fome occafions, the fwelling begins in the 
 fuperior part of the procefs ; but in gene- 
 ral, it is firft obferved towards its lower 
 extremity a little above the epididymis. 
 By degrees, however, it ftretches upwards, 
 and on fome occafions ^o far downwards 
 as to reach from the abdominal mufcles 
 to the very bottom of the fcrotum ; in 
 ■which cafe, a perfon not verfant in dif- 
 orders of this nature, may very probably 
 miftake this fpecies of hydrocele for a col- 
 lection in the tunica vaginalis teftis : But 
 we have here a very charadleriftic diftinc- 
 tion between the two difeafes. In the com- 
 
 mencemeat 
 
Sea. VL Of the Hydrocele, 47 j' 
 
 mencement of this fpecles of fwelling, the 
 tumor is always above the tefticle, which 
 is diftindly felt below it; and even in 
 the moft advanced flages of the diforder, 
 the teflis is found lying at the back part 
 of it, perfedly unconneded with the 
 fwelling : Whereas, in the advanced flate 
 of a hydrocele of the tunica vaginalis, al- 
 though fome degree of hardnefs is always 
 difcovered at that part where the vaginal 
 coat adheres to the tefticle ; yet in the lat- 
 ter period of that diforder, when the fwell- 
 ing is conliderable, the teftis itfelf can ne- 
 ver be diftindlly felt. In the fpecies of hy- 
 drocele we are now defcribing, the figure 
 and fize of the penis is not commonly fo 
 much altered, as when the water is collec- 
 ted in the tunica vaginalis, when the penis 
 is frequently made to difappear almoft en- 
 tirely. 
 
 In other particulars, the encyfted dropfy 
 of the fpermatic cord is very fimilar to the 
 hydrocele of the tunica vaginalis teftis. A 
 lluduation of a fluid is evidently difcover- 
 
 ed 
 
47^ Of ^^^^ Hj'^''ocele, Chap. VI, 
 
 ed on prefTare : The tumor is commonly 
 of A pyramidal form, as is generally too the 
 cafe with the other, with its bafe or largeft 
 extremity dowdwards * : And no prefFure 
 has any infiaence in making it difappear 
 either altogether or in part. 
 
 This is the appearance of the diforder 
 \^hen the water is contained in one cyfl ; 
 when it is feparated into two diftin<fl cells, 
 the line of divifion is commonly evident, 
 by the tumor being at that part fomewhat 
 puckered, or fometimes a little diminifhed 
 in its diameter. A iimilar appearance, we 
 snay obferve too, takes place when this fpe- 
 cles of fwelling is combined with a real 
 hydrocele of the tunica vaginalis teftis, 
 \vhich on fome occafions it is : And in 
 that cafe, a line of feparation is obferved at 
 
 that 
 
 * A Hydrocele of the tunica vaginalis teftis is Tq 
 frequently of a pyramidal form, with its bafe down- 
 wards, that this Ihape may be confidered as one of 
 the characleriftic appearances of the difeafe; every 
 other tumor to which the teftis and its coats are li- 
 able, being either more round, or of a more irregular 
 
Sed. VI. Of the Hydrocek, j^j-^ 
 
 that part where the upper extremity of the 
 tunica vaginahs terminates. 
 
 We have already mentioned the means 
 of difl;in(5lton between this fpecies of hy- 
 drocele and that of the vaginal coat of the 
 teftis. The only other affedions with which 
 it is in danger of being confounded, are the 
 anafarcous hydrocele of the fpermatic cord* 
 and a real hernia, either of the omentum j. 
 or of a portion of gut. From the former, 
 however, as alfo from an omental hernia, 
 it may in general be diflinguiflied by the 
 feel. In neither of thefe can the flucflua- 
 tion of a fluid be in the leaft perceived, and 
 to the touch they are both foft and inela- 
 ftic ; whereas, in this fpecies of hydrocele^ 
 the tumor has a fpringy kind of feel, and a 
 fludluation is evidently found in it. And in 
 both the others, the fweiling recedes more 
 or lefs upon prefTure, which it never does 
 ill this fpecies of encyfted hydrocele. 
 
 From a gut-rupture it is chiefly diflin- 
 guifhed by the tumor beginning, not at the 
 ring in the external oblique mufcle, as is 
 the cafe in hernia,, but farther down the 
 
 cord ; 
 
478 Of the Hydrocele, Chap. VI. 
 
 cord : In the latter, too, the fwelling com-*- 
 monly turns lefs on the patient getting 
 into a horizontal pofture; and it is always 
 confiderably afFedled both by coughing and 
 fneezing; but no pofture, no prefTure, nor 
 any accident whatever, alters the lize of 
 this variety of hydrocele. The abfence of 
 other fymptoms of hernia, too, is here ma- 
 terial in the diftindion : For there is nei- 
 ther pain in the tumor, nor in the abdo- 
 men ; nor ficknefs, vomiting, nor any in- 
 terruption to the pafTage by ftool, as there 
 very commonly are in hernia. 
 
 .Although all the ancient writers were 
 quite unacquainted with the anatomy of 
 the parts concerned in this diforder, it is 
 evident they were v/ell aware of its exift- 
 ence. We find it particularly defcribed by 
 iEgineta, Albucafis, and afterwards by Fal- 
 lopius, Wifeman, &c. Arnaud, in his trea- 
 tife on hernia, alfo takes notice of it, tho' 
 not with much accuracy ; and we find it 
 more lately defcribed with exadlnefs, by 
 the late Ddor Monro, by Douglafs, and by 
 Mr Pott. 4 
 
 This 
 
Sea. VI. ' Of the Hydrocele. 479 
 
 Thlsfpecies of hydrocele, as alfo the ana» 
 farcous fwelling of the cord, and the oede- 
 matous tumor of the fcrotum, are all very 
 frequent in infancy. In that tender age, 
 however, they generally foon diilipate, and 
 in this they are much afTifled by the appli- 
 cation of cloths dipped in fph'it of wine . 
 and 1 have feen much advantage produced 
 by an application of aftrong infulion of red- 
 rofe leaves, combined with a coniiderable 
 proportion of alum. The late Dodlor Monro 
 advifes the application of cloths warmed 
 with the fumes of burning benzoin. 
 
 But in adults, the cyfl confining the wa-» 
 ter generally becomes fo firm as not to be 
 affecled by any of thefe remedies. So that 
 when it arrives at any confiderable fize, 
 which it frequently does, either the means 
 for the palliative or radical cure may be 
 employed, as was recommended in the hy- 
 drocele of the tunica vaginalis tellis. 
 
 When it is intended merely to evacuate 
 the water by punflure, it ought to be done 
 with a trocar, in the fame manner as was 
 dircwled for a hydrocele of the tunica va- 
 ginalis I 
 
480 Of the Hydrocele. Chap. VI. 
 
 glnalis ; taking care to introduce the in- 
 flrument at the mod depending part of 
 the tumor. And again, when it is in- 
 tended to afFe(ft a radical cure, the fame 
 means are to be employed which we for- 
 merly recommended in the other fpecies of 
 the difeafe. There do not here, indeed^ 
 occur the fame objections to the ufe of the 
 feton, as in the hydrocele of the tunica va- 
 ginalis from the prefence of the tefticle : 
 And if we could in every fpecies of hy- 
 drocele afcertain with certainty the exacfl 
 contents of the tumor, the feton might no 
 doubt be employed here with fafety and 
 advantage : But as it is clear from what 
 ■we have already faid upon this point, that 
 no certainty of this kind can be obtained ; 
 and as a hydrocele of a hernial fac in 
 which a portion of gut is contained, may 
 be as readily confounded with this as with 
 any other fpecies of the difeafe; I would 
 therefore without hesitation lay this me- 
 thod of cure entirely afide. 
 
 A material objection occurs to the me- 
 thod of cure by Cauflic in this fpecies of 
 
 4 hydrocele, 
 
Se£i. Vi. Of the Hydrocele, 48 i 
 
 hydrocele, which is not applicable in the 
 hydrocele of the tunica vaginalis, viz. the 
 water being in fome inftances of this dis- 
 order colledled in two or more diftind^ 
 tyfts ; different cafes of which I have met 
 withi and fimilar occurrences are related 
 both by Garengeot and Douglafs. — Now iii 
 fuch an event, if caullic fhould be applied 
 in the method recommended by Mr Elfe, 
 tipoti a fmall fpot only, all the water would 
 iiot be evacuated ; and in order to obtain 
 a complete removal of the diforder, it 
 would be neceffary to repeat the applica- 
 tion of the cauftic. 
 
 This, 1 think, is an additional rfeafon for 
 employing in all fuch inftances the method 
 of cure by incifion ; which by laying the 
 tumor open from one end to the other, di^ 
 Tides dtonce all the different Cyfts of which 
 it may be cdmpcfed, and faves the patieni 
 ifrom that diftrefs and difappointment 
 which muft always be experienced, on a 
 complete cure not being obtained when 
 good reafons had been previoufly given for 
 expeding it. We would therefore advife 
 
 Vol. I. H h the 
 
482 Of the Hydrocele, Chap. VL 
 
 the treatment by incifion in this fpecies of 
 hydrocele, in the fame manner as was re- 
 commended in the hydrocele of the tunica 
 vaginalis ; the mode of performing the 
 operation, and the after- treatment of the 
 patient, being nearly the fame in each. 
 
 We have thus enumerated all the kinds of 
 hydrocele which can properly beconfidered 
 as forming diflindl varieties of the diforder. 
 In doing fo, as no difeafe is defcribed but 
 fuch as every pradicioner of experience 
 muft have met with, and of which the 
 fymptoms are clearly and diftinclly mark- 
 ed ; fo it will not, I hope, be confidered as 
 an unneceffary degree of minutenefs that I 
 have particularly taken notice of them all, 
 I can by no means agree with fome 
 authors, particularly with Mr Sharpe* and 
 Mr Elfe f, who think it might be better to 
 confine the defcription of this diforder to 
 two fpecies. We need not indeed wonder at 
 Mr Sharpe fpeaking in this manner: For 
 even at the late period in which he wrote, 
 
 although 
 
 * Treatife on the Operations of Surgery. 
 f Loco citato. 
 
Bte.. IVi Oflh^ Hydrocdi: 483 
 
 although the exlftence of all the varieties of 
 the difeafe we have mentioned had been 
 defcribed by different authors, yet they 
 were not till of late years underftood with 
 much accuracy; and it is very evident from 
 Mr Sharpe's writings on this fubjed, that 
 his ideas of thefe diforders were in many 
 refpe(5ts more confufed than could have 
 been expeded in one of his tifaal accuracy 
 and penetration. But whatever was the 
 cafe with Mr Sharpe, it is truly fur- 
 prifing, that thofe who are unqueftionably 
 well informed in every circumftanee re™ 
 lating to this diforder, and who muft 
 be convinced, from their acquaintance 
 with diiTedion, of the exiftence of all the 
 varieties of the difeafe that have been 
 mentioned, fhould object to their being 
 retained. Where no evident or marked 
 diftindlion occurs between one tumor and 
 another, an attempt to eftablifh a dif- 
 ference would be ufelefs, and therefore 
 improper ; but where appearances point 
 out an obvious variety, it would furely 
 be confidered as an unpardonable ne- 
 H h 2 gle^fl 
 
484 . Of the Hydrocele, Chap. VL 
 
 gled in an author to omit the detail of 
 them. 
 
 In our defcription of the five different 
 fpecies of hydrocele, viz. the anafarcous 
 fwelling of the fcrotum ; the hydrocele of 
 the tunica vaginalis teftis ; the hydrocele 
 of the hernial fac ; the anafarcous fwelling 
 of the fpermatic cord j and the encyfted 
 colle(flion in that part; it was necefTary in 
 going along to enumerate the fymptoms of 
 each as they occur feparately and uncom- 
 bined. It fometimes happens, however, 
 that one, two, or more of the different fpe- 
 cies occur at the fame time in the fame 
 patient: On fome occafions I have met with 
 three, and not unfreqnently with two, va- 
 rieties in the fame perfon: The lateDocflor 
 Monro mentions an inflance of four fpecies 
 of hydrocele being all combined in one 
 cafe *. 
 
 In fuch occurrences fome difficulty and 
 confufion is, no doubt to be expecfled; but 
 praditioaers in forming a judgment of 
 their nature, muft be entirely dire(fled by 
 
 a 
 
 ♦■ See his works, p. 57^. 
 
Se6l. III. Of the Hydrocele, 48^ 
 
 a due attention to the various rymptoms 
 which ufually occur in a feparate ftate in 
 each variety of the difeaie. 
 
 We now proceed to the confideration of 
 the other varieties of falfe hernia; and 
 firft of the Hematocele. 
 
 CHAP. VII. 
 
 Of the H-EMATOCELE. 
 
 THE Hsematocele is a tumor in the 
 fcrotum or fpermatic cord, produced 
 by extravafated blood. 
 
 The ufual feat of fuch tumors is in the 
 tunica vaginalis of the teftis ; but on fome 
 pccafions they are feated in the fpermatic 
 procefs, and now and then they are met 
 \vith in the dartos. 
 Tumors of this kind are in general pro- 
 H h 3 duced 
 
4S6 Of the Eamaiocde, Cbap.VH. 
 
 duced by the ruptvire of one or more 
 blood-velTels, in confequence of external 
 violence. Blows upon the fcrotum have 
 produced ruptures of veins, not only in 
 the cellular fubftance of the fcrotum, but 
 in the vaginal coat of the tefticle ; and ac-?- 
 cidents of a fimilar nature have produced 
 fimila,r afFedlions in the courfe of the fper- 
 
 T 
 
 matic cord ; And as the paps in this fitua- 
 tion are very lax and cellular, the rupture 
 either of an artery, or of a vein of any 
 coniiderable fize, will always be attended 
 "with a plentiful extravafation of their con- 
 tents. 
 
 In the tunica vaginalis teftis, this difor- 
 der is frequently induced by the point of a 
 trocar or of a lancet in tapping for a hydro- 
 cele, wounding fome of the blood- veffels 
 of the fac, which in fuch cafes are always 
 much enlarged. In fuch an occurrence, 
 we are commonly rendered certain of what 
 has happened, by the water drawn off be- 
 ing fuddenly tinged with blood ; but on 
 pther occafions it does not appear till the 
 ^ater is all evacuated, and then a tumor 
 
 of 
 
Chap. VII. Of the Hematocele. 487 
 
 of a confiderable fize is frequently produ- 
 ced in the courfe of a very fhort fpace of 
 time. 
 
 In fome of thefe cafes where the bulk 
 of water has been remarkable, the fudden 
 difcharge of it, by taking away the fop- 
 port which the veffels of the parr have been 
 for fome time accuftomed to receive from 
 it, has undoubtedly been the caufe of the 
 rupture of fome of them ; and from re- 
 peated obfervation 1 think it may be con- 
 fidered as a certainty, whenever a tumor is 
 produced either in the fcrotum or fperma- 
 tic cord, fuddenly after the water of a 
 hydrocele has been evacuated by tapping 
 that it is entirely the confequence of an 
 extravafation of blood ; for coUecftions of 
 water are never known to arrive fo quickly 
 at a confiderable fize. 
 
 In the fpermatic procefs, injuries of the 
 fame kind will be attended with a iimilar 
 effed upon the fmaller veins of the fae 
 containing the water ; and more confider- 
 able violence has on fome occa-fions pro- 
 H h 4 duced 
 
488 Of the Hamatocde, Chap. VIJ, 
 
 duced a rupture of the fpermatic artery 
 and vein. 
 
 But, in whatever way the tumor has 
 been produced, the appearances are nearly 
 fimilar to thole of watery collections in 
 the fame parts, fo that we do not confider 
 it as necefTary to repeat them here: Only 
 it may be obferved, that when blood is 
 extravafated in the fcrotum, it is eafily dif- 
 covered from a collecftion of water by the 
 colour, it being in every refpecl a real 
 Ecchymofis. When the fvvelling is feated 
 in the tunica vaginalis, the means of di- 
 flinguifliing between blood and water, is, 
 that a tumor produced by the former, feels 
 to be more heavy than water in propor- 
 tion to its bulk; and they who are much 
 accuftomed to handle fuch diforders, are 
 on many occafions fenfible of a difference 
 of coniiilence. 
 
 The treatment here is nearly the fame that 
 we have already recommended in cafes of 
 hydrocele. In the commencement of the 
 anafarcous or diffused fpecies of hsematocele, 
 ^hen produced by a flight external vio- 
 Jence, whether in the fcrotum or fperma- 
 tic 
 
Ghap. VII. Of the Hcsmatocek, 489 
 
 tic procefs, the application of ardent fpirits, 
 or of a folution of alum, will on fome oc* 
 cafions efFed its difcuffion : But when this, 
 upon trial, is not found tofucceed, the tu- 
 mor is to be laid open, and in every refpedl 
 treated in the fame manner as was dire(5led 
 for the hydrocele ; only, if a rupturedblood- 
 yelTel is difcovered, the only effedlual means 
 of preventing a return of the diforder is to 
 fecure it by ligature. 
 
 In the fame manner, all colle61:ions of 
 blood, either in the vaginal coat of the 
 teflis, or in the cyft of a former hydrocele 
 of the fpermatic cord, are to be laid open 
 by an incilion extending the whole length 
 pf the tumor, and are to be treated as we 
 formerly direded for hydrocele. And, as 
 we have already advifed in the difFufed 
 fpecies of haematocele, if any ruptured vef- 
 fel comes into view in the courfe of the 
 operation, it ought to be immediately fe- 
 cured by ligature. It fometimes happens, 
 however, in afFeclions of this kind, both of 
 the fpermatic procefs and tunica vaginalis 
 feftis, that the vefTels from whence the 
 
 blood 
 
490 Of the Hematocele, Chap. VII. 
 
 blood is difcharged cannot be detected; a 
 very confiderable oozing continuing from 
 day to day, notwithftanding the ufe of bark, 
 vitriolic acid, and every other means com- 
 monly employed in fuch cafes. 
 
 If, after a proper trial of all the ordinary 
 remedies ufed in cafes of haemorrhagies, 
 the veffels from whence the blood is difchar- 
 ged cannot be otherwife fecured, the end 
 in view may frequently be obtained by ex- 
 tirpation of the teflicle; wrhich, in fuch 
 occurrences, is the only remedy from which 
 any advantage is to be expecfled. 
 
 Another fpecies of haematocele is taken 
 notice of by Mr Pott, in which the blood 
 is contained within the tunica albuginea 
 of the teftis. It proceeds, he thinks, from 
 a relaxation or diffolution of part of the 
 vafcular ftrudure of the tefticle; and when 
 the quantity of blood colle(fled is confider- 
 able, it produces, Mr Pott remarks, a fluc- 
 tuation fomewhat like to that of an hydro- 
 cele of the tunica vaginalis. 
 
 When this happens to be miftaken for 
 2 a 
 
Chap. VII. Of the HamatoceJe. 491 
 
 a hydrocele, as ic has fometimes been, and 
 an opening with a trocar is made inta it, 
 a difcharge is produced, of a dark duiky- 
 coloured blood, nearly of the confidence 
 of thin chocolate; but although fome di- 
 minution may be made in the fize of the 
 tumor, by the evaciiation thus obtained, 
 yet no confiderable alteration is efFedted 
 by it. 
 
 Any perforation that is made into it, ac- 
 cordingly does no good; and as the tefticle 
 is commonly fo far fpoiled by the difeafe 
 as to be rendered quite ufelefs, caftration is 
 advifed as the only efFedlual remedy*. 
 
 I have different times met with a difeafe 
 very fimilar to this defcribed by Mr Pott : 
 But as the blood in fuch inftances did not 
 appear to be extravafated, but to be ftill 
 contained in the vefTels of the teftis in an 
 enlarged varicofe ftate, I would not incline, 
 therefore, to refer this kind of tumor to 
 any fpecies of haematocele. I have even 
 feen this diforder miftaken for a hydrocele, 
 and treated as fuch, by a trocar being 
 
 plunged 
 ^ Mr Pott's Treatlfe on the Hydrocele, 
 
4^2 Of the Hamatocele, Chap, VII. 
 
 plunged into it, when the efFedls were jnft 
 fuch as are defcribed by Mr Pott. But, if 
 the blood had been extravafated, a more 
 copious difcharge ought to have taken place, 
 in confequence of the operation, than was 
 procured by it in any of the cafes I have 
 met with: Even where the tumor has been 
 of a confiderable fize, I never found it pof- 
 fible to evacuate in this manner more than 
 a fpoonful or two of blood ; and although 
 in fuch cafes the blood appears evidently to 
 be thicker than it ought to be, yet it is by 
 no means fo much fo as fliould prevent it 
 from being freely difcharged by the canula 
 of a trocar if it was lodged in a ftate of ex- 
 travafation. But in all the inftances I have 
 ever feen of this diforder, the blood appeared 
 to be ftill contained within its proper vef- 
 fels in an enlarged varicofe flate; fo that, 
 inftead of confidering fuch a tumor as a 
 variety of hasmatocele, I would rather re- 
 fer it to a fpecies of Varix. 
 
 In any cafes of this kind that have oc- 
 curred to me, when the tumors were not 
 opened, but were entirely trufted to the 
 
 %- 
 
Cliap.VII. Of the Hematocele, 493 
 
 fupport afforded by a fufpenfory, they have 
 in fome inftances remained for many years 
 without being produ(flive of any mifchief: 
 And they are commonly attended with this 
 peculiarity, that when effectually fupported 
 by a bandage, they remain ftationary for 
 a great length of time, without acquiring 
 any additional fize ; a circumftance which 
 no fupport will prevent either in a hydro- 
 cele or in the real hsematocele. But as foon 
 as the tumor, by being miftaken for a hy- 
 drocele, is touched with an inflrument with. 
 a view to evacuate its contents, it is from 
 that moment fure to go wrong. The 
 patient, from being previoufly liable to 
 little or no pain, immediately on the tu- 
 mor being opened becomes very much 
 diftreffed ; the fwelling then begins to in- 
 creafe, and in a gradual manner to prove 
 fo troublefome by frequent difcharges of 
 blood, as to render caflration abfolutely 
 neceffary. 
 
 Even this difagreeable refource does not 
 always prove a certain relief; for it fome- 
 times happens, that fuch a fpongy relaxed 
 
494 Of the Hematocele, Chap. VIL 
 
 Hate of the vefTels occurs along the whole 
 courfe of the cord, that although they are 
 fecured by ligature to-day, the blood burils 
 out from different parts of the fore to- 
 morrow. I happened once to be concern- 
 ed in a very melancholy inftance of this 
 kind : Afcer the ufaal operation of caflra- 
 tion, freih hasmorrhagies occurred at every, 
 drefling ; the vefTels were at different times 
 fecured by ligature, but to no purpofe ; 
 the blood burft out again and again ; and 
 the patient, after fuffering much diftrefs> 
 at lafl died. 
 
 The only difference which, before laying 
 the parts open, can be obferved between 
 this fpecies of tumor and a real hydrocele 
 of the tunica vaginalis, is, that in this, the 
 fluctuation in the fwelling is never fo evi- 
 dent as in the other ; the tumor is heavy 
 in proportion to its fize ; and if properly 
 fupported by a bandage, it does not receive 
 any additional increafe. Whenever thefe 
 circumftances, therefore, occur in the fame 
 cafe, it ought to afford much reafon to 
 fufpedl that the fwelling is of this nature, 
 
 and 
 
Ghap. VII. of the H^matocsk, 49 jf 
 
 and that accordingly it ought not to be 
 meddled with. 
 
 As I confider this diforder to be entirely 
 of the varicofe kind, I would not have 
 thought of introducing the confideration 
 of it here ; but as it was proper to mention 
 its having been taken notice of by others as 
 a fpecies of hsematocele, I thought it better 
 to finifh the difcuffion of it at once, than 
 to be under the neceflity of bringing it in 
 again in a fubfequent chapter. 
 
 CHAP. VIII. 
 
 Of the Varicocele, Cirsocele, Sper« 
 MATOCELE, flW Pneumatocele. 
 
 BY the firfl of thefe terms is meant, a 
 varicofe diftention of the veins of 
 the fcrotum; which in this ftate form a 
 
 tumor 
 
49(S ^f ihe Cirfocek, ^c. Chap. VIIL 
 
 tumor of hard knotty inequalities, feldom 
 attended with pain, and in general pro- 
 dudlive of no inconvenience except what 
 arifes from its bulk. 
 
 The Cirfocele is a tumor of a nature fi- 
 milar to the former, in the courfe of the 
 fpermatic cord, extending from the fupe- 
 rior part of the fcrotum to the abdominal 
 mufcles, and produced by a varicofe dif- 
 tention of the fpermatic vein. 
 
 Both thefe afFedions are now and then 
 produced, by obftrudlion of one kind 
 or another in the veins of thefe parts : 
 but moll: frequently they depend on a 
 debilitated relaxed flate of the veins. 
 
 When tumors in the courfe of the veins 
 are detecfled as the caufe of fuch fwellings, 
 or when the prefTare of a hernial trufs up- 
 on the fpermatic procefs is difcovered to 
 be their origin ; the removal of this evi- 
 dent caufe of the difeafe ought to be thef 
 firft attempt towards a cure. 
 
 If the preflfure of a trufs has been the 
 caufe of the fwelling, an alteration in the 
 baadage may probably remove it. If 
 
Chap.VIir. Of theVaricocek, 497 
 
 tumors of a hard fcirrhous nature have 
 produced ic, their extirpation, when that is 
 found to be praclicable, Vv'ili be the mofb 
 efFedual means that can be employed ; and 
 if the tumors have any tendency to fjp- 
 purate, vi-arm emollient applications will 
 be more ufeful than any other remedy. 
 
 But when a general relaxed fiate of the 
 veins is fufpecf^ed to give rife to the com- 
 plaint, fuch remedies ought to be employed 
 as will moft effectually recover that tone, 
 of which they have been deprived bv be- 
 ing long over-diilended. For this purpnfe 
 nothing commonly anfwers fo well as the 
 life of a proper fufpenfory bandage ; a ho-- 
 rizontal pofture ; the cold bach ; and the 
 application of a folution of alum and other 
 aftringents, to the parts affecled. 
 
 By a due continuation of thefe means 
 every affecl:ion of this kind mav be always 
 prevented from increaling, and will com- 
 monly be fo far relieved as to render theharih 
 means by the knife, the cautery, and liga- 
 ture, recommended by ancient writers for 
 the removal of fuch tumors, unneceJlary. 
 Vol. I. 1 i B7 
 
. 49^ Spermatocele /^c. Chap.VIIL 
 
 By the tenn Spermatocele, is meant, a 
 morbid didention of the epididymis and 
 vas deferens, produced by a flagnation of 
 femen. This may be produced by tumors, 
 llricliure, or inflammation, abaut the capuf 
 gaUinaginis^ or in the courfe of the vas de- 
 ferens ; but there is reafon to think, that it 
 is more frequently induced by the laft, 
 viz. by inflammation, than by either of 
 the -other two. 
 
 When an inflammatory afFeclion of the 
 parts is difcovered to be the caufe of the 
 difeafe, general and topical blood-letting, 
 gentle laxatives, a low cooling diet, and reft 
 of body, v^rill commonly be faund the moft 
 eiFe^ftual remedies. And again, when tu- 
 mors are difcovered to prefs upon the vas 
 deferens^ they ought either to be brought to 
 fuppurate, or their extirpation fhould be 
 attempted when that can be done with^pro- 
 priety. At other times, thefe tumors are 
 found to depend on a venereal caufe ; and 
 in fuch inftances a well-dire6led courfe of 
 mercury has been known to remove them. 
 
 On forne occaflons we are told, that all 
 
 the 
 
Chap. VIII. Of the Pneumatocele^ 495 
 
 the other means having failed, caflration 
 has at laft been found requifite. This, 
 however, we cannot fuppofe to be ever a 
 very neceflary meafure. 
 
 The term Pneumatocele, is applied to 
 fignify a diftention of the fcrotum by a 
 colledlion of air. 
 
 This has been defcribed by moft of the 
 ancient writers as a very frequent occur- 
 rence ; but there is much reafon to think, 
 that a great proportion of all the tumors 
 they take notice of as containing air, were 
 either formed by colledlions of water, or 
 by a protrufion of fome of the bowels. 
 That fpecies of hernia to which young 
 children are liable, is to this day by our 
 common people termed a Wind Rupture ; 
 as are all thofe collecflions of water in the 
 fcrotum with which new-born infants are 
 affected : But we know vsrell, that none of 
 thefe tumors are formed merely by wind 5 
 their contents being of a very different na* 
 ture. 
 
 In wounds of the lungs, air is fbmetimes 
 
 thrown into the furrounding cellular fiib- 
 
 I i 2 fiance, 
 
300 Cf the Pneumatocele, Chap. VII f. 
 
 ftance, and in that way pafTes into the 
 fcrotum,- as it does in particular inftances 
 over the whole body; and in high degrees 
 of putrid difeafes, fo much air may be fe- 
 parated from the blood, as to diftend the 
 cellular fubftance of the fcrotum, as well 
 as of other parts : But a real pneumatocele 
 has never, probably, exifled as a mere local 
 afFedion of the fcrotum ; at lead I have 
 never feen it. 
 
 In the cafe of air difFufed into the cellu- 
 lar fubflance of thefe parts, in confequence 
 of a wound or any other afFeclion of the 
 lungs producing an extravafation of it, the 
 fame method of cure will anfwer for its 
 removal that we recommended for anafar- 
 cous fwelllngs formed by water, viz, fmall 
 pun6lures with the point of a lancet, which 
 are found to be fully fufficient for evacua- 
 ting great quantities of air. But whenever 
 the difeafe is induced by fuch a great degree 
 of putrefcency in the fyftem as is neceffary 
 for efFe6ling a feparation of air from the 
 blood, there can be lictle reafon to expedl 
 any advantage to refuk from whatever 
 means may be employed for relief. 
 
 CHAP. 
 
Chap. IX. Ofihe Sarcocek. 505 
 
 CHAP IX. 
 
 Of the Sarcocele, or Scirrhous 
 Tes ticle. 
 
 BY the term Sarcocele, is underftood, a 
 firm flefhy kind of enlargement of the 
 tefticle : A limple inflammatory afFecflion 
 of the teftis affords a tumor of fome de- 
 gree of firmnefs ; but the true farcocele, or 
 fcirrhous tefticle, is attended with a hard- 
 nefs never to be met with in the r^al hernia 
 humoralis or inflamed tefticle. 
 
 A fcirrhous tefticle, in the courfe of its 
 progrefs, pucs on fuch a variety of appear- 
 ances, as renders it difficult by defcription 
 to give an adequate idea of it : In general, 
 however, the acceflion and progrefs of the 
 difeafe is as follows. 
 
 I i 3 iVii 
 
5^"^ Of the Sariocele, Chap. IX. 
 
 An iinufual degree of hardnefs, attended 
 ■with a trifling enlargement of the whole 
 teftis, proves in general to be the firfl indi- 
 cation of the difeafe ; In the beginning, no 
 difcolouration is obferved, nor is there any- 
 material pain : In a gradual manner the 
 tumor acquires a larger fize : As yet it re- 
 mains fmooth and equal on its furface ; 
 but with the fize of the fwelling, the hard- 
 nefs alfo becomes more remarkable *. Slight 
 pains are at times felt through the fub- 
 flance of the tumor ; and if it be not fuf- 
 pended the patient complains of fome un- 
 eafinefs in his back. 
 
 When there is nothing particularly bad 
 in the conftitution, the diforder will on 
 fome occafions remain in this fituation for 
 a great length of time ; and in a few in- 
 ilances, by a moderate diet, keeping an 
 open belly, fufpending the tumor proper- 
 ly, and avoiding violent exercife, the dif- 
 order has not only been prevented from in- 
 creafing, but has in a gradual manner difli- 
 pated: Such favourable occurrences, how- 
 ever, it mufl be owned, are exceedingly 
 
 rarp ; 
 
Chap. IX. Of the Sarcocek, 503 
 
 rare; for the fwelling, inftead of dlfcufling, 
 or remaining flationary, in general pro- 
 ceeds with more or lefs rapidity to turn 
 worfe. The tnmor acquires a larger iize j 
 becomes ragged and unequal on its fur- 
 face ; and the pain, which at firft was tri- 
 £ing/ becomes more fevere, darting, in 
 fmart flings through the fubflance of -the 
 tumor. 
 
 The inequalities on the furface of the 
 tumor by degrees increafe, and continue to 
 retain the fame kind of hardnefs with the 
 fwelling from which they originate : On. 
 fome occafions, a coniiderable quantity of 
 ferum is extravafated into the tunica vagi- 
 nalis, which, to thofe net acquainted with 
 the nature of fuch diforders, gives the tu- 
 mor the appearance of a common hydro- 
 cele : And at other times, inftead of fuch 
 depoHtions into the vaginal coat, partial 
 colle6lions of matter are formed through 
 the whole body of the tumor : Thefe by 
 degrees increafe ; and the fcrotun' , which 
 has hitherto been gradually diftending, at 
 laft bur us, and a difcharge takes place 
 114 froqa 
 
504. Of the Sarcocele Chap. IX. 
 
 from ihe various colleclions in the body of 
 the tumor, of a thin, fetid, bloody matter. 
 On fome occaGons, the fpermatic cord 
 beconies hard and enlarged foon after the 
 commencement of the difeafe ; but in ge- 
 neral the cord does not become affecled 
 till the tumor has acquired a confiderable 
 fize, and mofl: frequently, I have obferved, 
 not till matter has formed in fome part or 
 other of the fwellin??. 
 
 o 
 
 As the diforder of the tefticle advances, 
 this aifcclion of the cord alfo becomes 
 worfe : From being at firfl only flightly 
 tumefied, it gradually turns more hard and 
 fweiled ; it becomes very painful, and 
 knotty or unequal through the whole ex- 
 tent of it. 
 
 The difchar:^-e from the ooenin^s in the 
 fcrotum fbill continues : But although the 
 matter increafes in quantity, the fize of the 
 tumor is not thereby diminiflied; on the 
 contrary, it Hill continues to increafe : The 
 edges of the fore become hard, livid, and 
 I'etorted ; and fungous excrefccnces pufli 
 fi^i fvoiJi different parts of it. 
 ^' What 
 
Chap. IX Of the Sarcocsk, 505 
 
 Whatever was the flate of the patient's 
 conflitution on the firft attack of the dif- 
 eafe, in this advanced ttate of it, it is al- 
 ways greatly impaired: He now becomes 
 emaciated ; of a pale, wan complexion; and 
 the diforder, which in this ftage of it is a 
 real cancer of the mofl malignant nature, 
 turning ftill more virulent, by the pain be- 
 coming more tormenting, the patient is at 
 Jaft carried off in very great mifery. 
 
 Such, in general, is the progrefs and event 
 of this dreadful diforder, if it be not inter- 
 rupted by extirpation of the tefticle before 
 the fwelling has proceeded too far. We 
 have already faid that it exhibits a great 
 variety of fymptoms: Thofe here enume- 
 rated occur mod frequently; bat no de- 
 fcription can convey a clear idea of all the 
 appearances it afTumes. On fome occa- 
 fions, v;e have already obferved, it re- 
 mains apparently in an indolent, inadive 
 ftate, for a great length of time, even for 
 years; and in others, it proceeds fo rapidly, 
 diat in the fpace of a few months it has 
 
 been 
 
$q6 Of the Sarcocele. Chap. IX. 
 
 been known to pafs through all the various 
 changes we have enumerated. 
 
 In by much the greateft proportion of 
 fuch affedlions the diforder begins in the 
 body of the teftis, aiSfecling the w^hole of it 
 equally ; but now and then it makes its 
 firft appearance in the epididymis, and 
 fometimes even in the fpermatic cord. 
 \t has been a prevailing opinion, indeed, 
 that a fcirrhous hardnefs tending to can- 
 cer, never does begin in the epididymis ^ 
 but that the tefticle is always firft afFecfled. 
 This is certainly the cafe in general; but 
 €very praditioner muft at times have met 
 Tvith cafes of a real cancerous nature, be- 
 ginning in the epididymis, and fometimes 
 even in the fpermatic cord, and fpreading 
 from thence to the neighbouring parts. — 
 I might here infert different cafes of this 
 nature, which have fallen within my own 
 obfervation; but Mr Pott*s colledion fur- 
 nifhes a fufficient number of well-marked 
 examples of the facl*. 
 
 In aimoft every cafe of fwelled tefticle 
 
 from 
 
 Treatife on the Hydrocele, Cafes 42. 48. and 49. 
 
Chap. IX. OftheSarcocele, 507 
 
 from a gonorrhoea, the epididymis is not 
 only afFecled before the tefticle, by the in- 
 flammation in fuch cafes fpreading from 
 the urethra along the vas deferens, when of 
 courfe it mud firfl reach the epididymis ; but 
 the diforder in fuch cafes, when it begins to 
 yield, always firft removes from the tefticle, 
 leaving in general a fcirrhous hardnefs in 
 the epididymis, which on fome occafions in 
 the courfe of time diflipates entirely, and in 
 others remains of the fame degree of hard- 
 nefs for a confiderable time, and now and 
 then even for life. But as the hardnefs pro- 
 duced in this manner is merely the confe- 
 quence of inflammation upon a membra- 
 nous or vafcular part ; fo here as in other 
 parts of the body of a fimilar texture, we 
 feldom find, that hardnefs thus induced 
 terminates in any thing bad. 
 
 The contrary, however, of this has been 
 too much inculcated. It has been faid, that 
 the hernia humoralis produced by a vene- 
 real infection, is a frequent caufe of the 
 worft kind of fcirrhous tefticle; which, as 
 fhe fadl is very much otherwife, has this 
 3 improper 
 
5o8 Of the Sarcocek, Chap. IX. 
 
 improper tendency, that it prevents the 
 ufe of, and a proper perfeverance in, fuch 
 courfes of medicine, as might, without the 
 neceflity of extirpation, have removed it : 
 There have even been inftances of this idea 
 being fo improperly appHed, as to be the 
 means of different teftes being extirpated, 
 which were evidently difeafed from a ve- 
 nereal caufe, and which by proper courfes 
 of mercury might in all probability have 
 been removed. 
 
 But although I have faid that afFedions 
 of this nature, I mean a fwelling of the 
 teftis from a venereal caufe, are very feldom 
 known to end in any thing bad ; yet I will 
 not go fo far as to fay that they never do 
 fo: For I know, that a hardened ftate of the 
 teftis and epididymis, produced originally 
 by a venereal taint, does in fome inftances 
 degenerate into the worft fpecies of farco- 
 cele; that is, that though affecflions of this 
 kind do moft frequently terminate eafily, 
 yet that now and then in particular confti- 
 tutions, whofe peculiarities, however, we 
 are not acquainted with, they do certainly 
 
 produce 
 
Chap. IX. Of the Sarcocek, 509 
 
 produce fcirrhofiities of the very worfl kind, 
 when fuch ailments would never probably 
 have appeared if the original venereal taint 
 had not occurred as an exciting caufe of 
 the diforder. We know well, that a predif- 
 pofition to different diforders will remain 
 long in a latent flate in the fyftem, without 
 being productive of any evident afFecflion, 
 till the application of fome particular fli- 
 mulus brings it into adion : In the fame 
 manner, a venereal inflammatory affection 
 of the teftis, will in fome conftitutions ter- 
 minate in much mifchief, although in ge- 
 neral its effeds in this way are by no means 
 to be dreaded. 
 
 I have dwelt longer upon this point than 
 I other wife fhould have done, from a con- 
 trary do(flrine having been ftrenuoufly in- 
 culcated by one whofe authority is defer- 
 vedly great, and whofe obfervation in this 
 difeafe has led to the conclufion he endea- 
 vours tt> eftablifh*; But as all the expe- 
 rience I have had in thefe matters, has 
 led me to form the opinion here delivered, 
 
 3 I 
 
 * Mr Pott, Treatife on the Hydrocele^ &c. p. 232. 
 
3'iG) Of the Sarcocek, Chap. IX. 
 
 I could not avoid dating it in the manner 
 I have done. 
 
 In the treatife alluded to, we are told^ 
 that a hernia humoralis is never, in any one 
 inftance, productive of this difeafe. If on 
 this fubje(5l Mr Pott's idea is juft, it ought 
 undoubtedly to be received : But if it ife 
 not, it may very certainly do mifchief, by 
 rendering both patients and practitioners 
 more remifs in cafes of farcocele proceeding 
 from this caufe than they otherwife would 
 bfe; as, by continuing ftill in hopes of a 
 mercurial courfe being able to efFedl a cure^ 
 they may thereby allow the difeafe to go 
 too far even for extirpation to be advife- 
 able. 
 
 In every doubtful cafe of this kind^ 
 when a venereal infecflion is fufpecfled 
 as the caufe of the difeafe, blood-letting 
 when the pulfe is full ; an open belly ; 
 a cooling diet ; a horizontal pofture ; 
 with a proper fufpenfory bandage; and 
 a well direded mercurial courfe, will 
 very commonly remove it. But when 
 
 in 
 
Chap. IX. OftheSarcocek. 511 
 
 in fuch in{lance,s the means recommended / 
 are put in pracflice without any evident 
 advantage; and efpecially if, during their 
 application, the diforder, inftead of mend- 
 ing, turns gradually vsrorfe ; as foon as 
 from its increafe in fize there appears to 
 be any rifk of its advancing beyond the 
 reach of operation, it ought then at all 
 events to be extirpated, whatever the caufe 
 which originally produced it may have 
 been. 
 
 Among other caufes mentioned by authors 
 as being productive of a fcirrhous ftate of 
 the tefticles, is the hydrocele of the tunica 
 vaginalis. From quantities of a watery 
 fluid being frequently found in the vagi- 
 nal coat of a fcirrhous tefticle, it has been 
 fuppofed, that the water in fuch cafes was 
 the original caufe of the difeafe in the teftis, 
 and not the confequence of it. There is 
 every reafon, however, to think, that in 
 thefe colledlions of water in the vaginal 
 coat, in which the teflis is found difeafed, 
 that the hardened ftate of that organ ought 
 to be conlidered as the original diforder, ' 
 
 and 
 
j;i2 OftheSarcocele. Chap. IX. 
 
 and not the quantity of water which fur- 
 rounds it, 
 
 Collecflions of water are no doubt often 
 met with, even in the real farcocele ; buC 
 this ought to be confidered only as a diffe- 
 rent ftage of the fame difeafe : For altho' 
 the true fcirrhous tefticle is never at firfl: 
 attended with any collection of this na- 
 ture, it is natural to fuppofe, that a hard 
 difeafed ftate of that vifcus mud have 
 fome influence in producing an alteration 
 in the quantity of fluid with which the 
 tunica vaginalis is always provided in a 
 found healthy flate. If it either produces 
 an augmented fecretion, or a diminifhed 
 abforption of that fluid, a dropfical fwell- 
 ing muft be the certain confequence; and 
 every fuch colieclion, combined with a 
 fcirrhous tefticle, has been very properly, 
 termed a hydro-farcocele. 
 
 That the teftis, by remaining long im- 
 merfed in the water even of a true hydro- 
 cele, does frequently become fomewhac 
 altered in its texture, there is no reafon to 
 
 doubr-5 
 
Chap. IX. of the SarcoceleV 513 
 
 doubt. Thus, as we have elfewhere ob- 
 ferved, on laying open the tunica vagi- 
 naUs, the teftis in that difbrder is always 
 found to_ be of a more pale appearance 
 than it naturally ought to be: On fome 
 occallons it is very much diminifhed, and 
 on others confiderably enlarged ; but all 
 fuch enlargements, when connected with 
 a real hydrocele, are of a fofc harmlefs na- 
 ture, fuch as never give any pain ; and in 
 this flate the teftis ought never to be ex- 
 tirpated. 
 
 This is a point, we rnay remark, which 
 it is of fome importance to afcercain : For 
 on the idea of thefe enlargements of the 
 teftes, frequently connetfled with, and per- 
 haps produced by, their immerfion in the 
 water of a hydrocele, being of a real fc;ir- 
 rhous nature, their extirpation has been 
 often advifed, and unfortunately too often 
 pradlifed. 
 
 In circumftances of this kind the means 
 of diftindlion between the mild and ma- 
 lignant fpecies of enlarged cefticle, by 
 
 Vol. I. K k which 
 
5^4 Q/' ^^'^ Sarcocek. Chap. IX. 
 
 which wc fhould in general be diredled, 
 are the following. 
 
 When the body of the teftis becomes 
 hard and enlarged, previous to any col- 
 lecSlion of water in the tunica vaginalis, 
 fuch colle<5lions as afterwards occur oughc 
 not to be conGdered as conftituting aiimple 
 hydrocele ; and if, upon evacuating the 
 water by inciiion, the teftis, befides being 
 enlarged, is found in a hardened ftate, and 
 ' efpecially if it is attended with pain, and 
 is ulcerated on the furface, extirpation 
 ought undoubtedly to be advifed imme- 
 diately : And, on the contrary, when the 
 water of a hydrocele is known to have 
 been collected while the tefticle remained 
 found and of its natural fize, whatever 
 enlargement it may be found to have ac- 
 quired on laying the fac open, if the te- 
 ftis is neither of a fcirrhous hardnefs, nor 
 afFe(fted with pain or ulceration, we ought 
 unqueftionably to proceed as in a cafe of 
 iimple hydrocele ; for any enlargement of 
 this kind will be rarely found to occafion 
 future uneafinefs, and confequently will 
 feldomorneverrenderextirpationnecefrary. 
 
 la 
 
Chap. IX, Of the Sarcocde, 515 
 
 In forming a prognoiis of this diforder, 
 different circumftances are to be attended 
 to ; the age, and habit of body, of the pa- 
 tient; the duration of the difeafe, and the 
 itate it is in at the time. 
 
 Thus, whatever treatment is to be adopt- 
 ed, more fuccefs may be reafonably ex- 
 pecEled in a young heahhy conflitution 
 than in the reverfe ; particularly if extir- 
 pation of the teftis is to be advifed. In 
 the former, the chance of fuccefs from the 
 operation is commonly confiderable, pro- 
 vided the diforder be not too far advanced 5 
 whereas in old, infirm people ; and in ha- 
 bits attended with pale, wan complexions • 
 with indigeftion ; and other fymptoms of 
 obftrufted vifcera ; whatever ftate the difeafe 
 may be in, little or no advantage can be ex- 
 pe(fled to accrue from any operation. 
 
 With refpeifl to the duration of the dif- 
 eafe, if it has already fubfifted for a confi- 
 derable time without making much pro- 
 grefs, there will be great reafon to think 
 that it is of a mild nature; and that the 
 fyftem, in general, is not fo much affedled 
 K k 2 . bv 
 
5 1 6 Of the Sarcocek, Chap. IX. 
 
 by it as if its progrefs had been great and 
 rapid ; and laflly, the ftate of the difordei* 
 for the time is of much importance in 
 forming an opinion of its final event. As 
 long as the tefticle is only fomewhat hard 
 and enlarged, without the formation of 
 matter, and without any difeafe of the cord, 
 if the conftitution is otherwife healthy, 
 there will be much reafon to expe6l a fa- 
 vourable event from any operation that 
 ought to take place. 
 
 But on the contrary, when the diforder 
 is fo far .advanced that collecflions of mat- 
 ter have formed, either upon the furface 
 of the tedicle, or in its more internal parts, 
 as in that (late the conftitution will pro- 
 bably have fufFered from abforption, fo 
 there is lefs chance of the operation in 
 thefe circumftances proving fo fuccefsful 
 as in the more early period of the dif- 
 eafe : And this is ftill more remarkably 
 the cafe when the tumor has become ul- 
 cerated externally ; for we know well, that 
 in all fuch cafes, the fyflem is much more 
 apt to fuffer from abiorbed matter on the 
 
 parts 
 
Chap. IX. Of the Sarcocele, 5 1 7 
 
 parts being laid open, than while they re- 
 mained excluded from the exterixal air. 
 
 In whatever flate, however, the tumor 
 may be, there is always reafon to expect 
 more fuccefs from the operation while the 
 fpermatic cord is yet found,' than when it 
 has become much difeafed ; for, as foon as 
 the cord is materially affedled, the chance 
 of fuccefs from any means to be attempted 
 is always proportionably lefTened. The 
 cord, indeed, may towards its under ex- 
 tremity be difeafed, even in the fame 
 manner vv'ith the tefcis itfelf, without lef- 
 fening the chance of benefit from the ope- 
 ration ; but whenever the diforder has 
 fpread fo far up the fpermatic procefs as 
 to render it doubtful whether the parts 
 affecfted can be all removed by the knife 
 or not, and efpecially when it is once ren- 
 dered clear that the cord is difeafed with- 
 in the boundaries of the abdomen, inftead 
 of there being in fuch circumftances any 
 advantage to be expecled from the opera- 
 tion, every attempt towards the removal 
 of the parts below, will for certain tend to 
 ^ k 3 _ ag= 
 
^i8 Of the Sarcocele, Chap. IX. 
 
 aggravate every fymptom, and will be a 
 means therefore of forwarding the patient's 
 death. 
 
 Whenever a fcirrhous or cancerous tu- 
 mor is fo fituated as to render its total re- 
 moval by the knife quite pradlicable, if 
 ought always to be advifed ; but when the 
 difeafe has advanced fo far as to render 
 this impoffible, in whatever part of the 
 body it may be fituated, no attempt of 
 this kind ought to be made, the fa6l being 
 now clearly afcertained, chat cancerous af- 
 fedlions are always rendered worfe by ex- 
 tirpation, when all the difeafed parts can- 
 not be removed. 
 
 It is of much importance, however, to 
 obferve, that the fpermatic cord is in this 
 diforder frequently affecfled with a fulnefs 
 and thicknefs of its parts, produced merely 
 by the weight of the tumor, without be- 
 ing in any other refpecl difeafed. A ful- 
 nefs of this kind, when no pain occurs in 
 the cord itfelf, and when there are no 
 knots or inequalities upon its furface, ought 
 never to prevent the operation, when in 
 
 other 
 
Chap. IX. Of the Sarcoceh^ 51 q 
 
 other rerpe(51s it appears to be necelTary; as 
 a mere enlargement of it very frequently 
 occurs, either from a varicofe flate of the 
 veiTels, or from a Vv'arery depoiition in the 
 cellular fubftance of the part, when the 
 procefs is not in any other manner dif- 
 eafed*. But on the contrary, when the 
 cord, at the fame time that it has become 
 confiderably enlarged, hard, and knotty, 
 adheres to the neighbouring parts, is pain- 
 ful to the touch, and efpecially if it is al- 
 ready ulcerated ; thefe, if the diforder ex- 
 tends over the whole procefs up to the ab- 
 dominal mufcles, are circumflances which, 
 with every prudent pradtitioner, will at ail 
 times forbid the operation of caftration. 
 
 it has indeed been propofed, in fuch a 
 
 ftate of the cord, to enlarge the opening in 
 
 the external oblique mufcle, fo as by dlf- 
 
 fedlion to trace the difeafed pares even into 
 
 K k 4 the 
 
 * Of what is here inculcated we have fome fing'a- 
 lar proofs in Mr Pott's Colle£iion of Cafes, which we 
 have fo often referred to as a dep'ofitary of ufeful fatfls. 
 See Cafes xxxix. xL xlix. and 1, Treatife on the Hy- 
 drocele. 
 
520 Of the Sarcocek. Chap. IX. 
 
 the cavity of the abdomen, with a^iew to 
 extirpate them entirely. But although the- 
 oretical writers may attempt to amufe their 
 readers with fuch propofals, they will never 
 be ferioully thought of by praditioners 
 whofe opportunities for obfervation enable 
 them to think and adl for themfelves. 
 
 We do not think it necelTary to fay any 
 thing, either of the effect of internal me- 
 dicines, or of external applications, in the 
 rem.oval of this difeafe ; for in the real far- 
 coccle, or fcirrhous teflicle, no remedy 
 with which we are acquainted has any 
 kind of influence. Even cicuta, the powers 
 of which are fo much extolled, does not 
 appear to be in any degree ufeful, either 
 in carrying off the diforder entirely, or in 
 mitigating any of its fymptoms. The only 
 remedy, therefore, from which we atprefent 
 reafonabiy expecl any advantage, is the re- 
 moval of the difeafed- parts by extirpation ; 
 fo that the mod important matter to be here 
 determined, is that period of the difeafe in 
 which the operation is mod advifable. 
 
 We have already obferved, that cafes of 
 
 fcir- 
 
f n 
 
 Chap. IX. Of the Sarcocele* 5 
 
 fcirrhous teflicle do now and then occur 
 with which patients go about for a great 
 length of time with little or no inconve- 
 nience : Such inftances, however, are ex- 
 ceedingly rare ; for, by much the greateft 
 proportion of all fuck affecftions, prove to 
 be of a dangerous malignant nature. 
 
 With refpecl to this point, therefore, we 
 may fhortly determine, that, whenever a 
 fcirrhous or hardened flare of the teflicle 
 does not yield to the means commonly 
 employed, fuch as moderate evacuations 
 of blood when thefe are indicated ; a foft 
 eafy diet-; a lax belly; the ufe of a fufpen- 
 fory bandage ; and efpecially when mer- 
 cury^ which, on the chance of the diforder 
 being venereal, is very commonly tried, 
 all are ufed without any effedl; we may in 
 fuch circumflances always have great caufe 
 to fufpe6l that thedifeafe is of a truly bad 
 nature. When more inveterate fymptoms 
 appear ; when the tumor, which till now 
 was in a hard indolent flate, becomes pain- 
 ful, and is evidently going on to acquire 
 an additional bulk; no farther delay ought 
 
 then 
 
522 ^f the Sarcoceie, Chap. IX. 
 
 then to be advifed : For however improper 
 it would be to remove a hardened tellis, 
 which for a confiderable time had remain- 
 ed indolent, without pain or any increafe 
 in bulk, yet it would be equally unpardon- 
 able in any praclitioner to recommend a 
 delay of the operation when matters are fo 
 far changed that the tumor is become pain- 
 ful, and is daily becoming larger. In fuch 
 circumftances, the fooner the difeafed parts 
 are removed, the greater will be the chance 
 of a recovery, and not a day therefore 
 fliould be loft. For whatever may have 
 been the opinion of a few individuals on 
 this point, it has long been a fixed maxim 
 with the moft experienced furgeons, that, 
 in all fcirrhous or cancerous aiFedlions, the 
 rifk of a relapfe after the operation is com- 
 monly in proportion to the duratioa of the 
 original difeafe *. 
 
 The 
 
 * The opinion of the late Mr Sharpe on this point 
 was Gngular in a man of fuch extenfive experience. 
 He confidered the rife of a relapfe after extirpation in 
 cancerous tumors to be greater in the more early pe- 
 riods of thefe difeafes than in their more advanced 
 {lates. Critical Inquiry y 4th edit. p. 108. 
 
Chap. IX. OftheSarcocek, 523 
 
 The extirpation of the tefticle being at 
 laft determined upon, the method of per- 
 forming the operation is this : The patient 
 muft be placed in a horizontal pofture on 
 a table of a convenient height, with his 
 legs hanging down, to be firmly fecured 
 by an affiftant on each fide. The parts 
 being previoufly fhaved, if the tumor is 
 very large, an afliftant muft be employed 
 to fecure it properly ; if only, however, 
 of a moderate fize, it is better for the fur- 
 geon to do it himfelf. With one hand^ 
 therefore, he ought to grafp the fwellingfo 
 as to keep it firm, and with a fcalpel in the 
 other fliould make an incifion along the 
 whole courfe of it, beginning at leaft an 
 inch above the part where the cord is to be 
 cut, and continuing it through the fl^in 
 and cellular fubftance to the inferior point 
 of the fcrotum. The eafieft method of 
 doing this, we may obferve, both for the 
 furgeon and patient, is by one continued 
 ftroke of the knife ; as it is both more 
 quickly and more neatly performed- in this 
 manner, than in the ufual way of pinch- 
 
 3 ing 
 
524 Of the Sarcocele, Chap. IX. 
 
 ing up the fkin between the finger and 
 thumb before cutting it ; and there is no 
 kind of difficulty or rifk in doing it in the 
 manner we have here directed. 
 
 Thefpermatic cord being thus laid bare, 
 the furgeon is now with the finger and 
 thumb of one hand to endeavour to fepa- 
 rate the fpermatic arteries and veins from 
 .xh€'uas deferens; which is for the mod part 
 eafily done, and which ought never to be 
 omitted, for it is in no degree necelTary to 
 include the nerve in the ligature : And this 
 being done, a firm, waxed flat cord, com- 
 pofed of a number of fmall threads, is 
 by means of the curved needle, Plate V, 
 fig 4. to be carried round the blood-vefTels, 
 which are thus to be fecured by a running 
 knot about a quarter of an inch above 
 that part of the cord which is to be di- 
 vided. 
 
 The cord being at this part cut acrofs, 
 the tefticle is then to be entirely removed 
 by difTecfling the cord and it from above 
 downwards, fo as to feparate them as eafily 
 as polTible from the furrounding parts. 
 
 Different 
 
Chap. IX. Of the SarcoceTe, $%$ 
 
 Different contrivances have been propofed 
 for facilitating the feparation of the teftis 
 from the contiguous parts ; but no inven- 
 tion with which we are acquainted anfwers 
 this purpofe fo well as a fcalpel. 
 
 When the difeafed parts are all removed, 
 the knot upon the cord fhould be untied, 
 in order to difcover the fpermatic artery 
 and vein, which by means of the tenacu- 
 lum may generally be feparated from the 
 nerve with which they are in conta<£l ; and 
 whenever this can be done, they ought 
 unqueflionably to be fecured in this man- 
 ner ; for, by including the nerve, no ad- 
 vantage whatever is obtained, and it al- 
 ways renders this a very painful part of 
 the operation. I have feen more pain, in- 
 deed, complained of in tying the fpermatic 
 cord in the ufual way, than 1 v^as ever 
 witnefs to in any ,part of almoft any ope- 
 ration; fo that whenever the nerve can be 
 feparated from the other parts, as it very 
 commonly with a little attention may be, it 
 ought always to be left out of the ligarure*. 
 
 3 When 
 
 * Vide Chirurglcal Cafes and Obfervations, by M,r 
 Bromfield, Vol. I. p. 336. 
 
<26 , Of the ^arcocele. Chap. IX. 
 
 When it fo happens, however, that this 
 cannot be done, the ligature muft then 
 be appUed in the ordinary manner, and 
 be made to furround the blood-vefTels and 
 nerves indifcriminately ; care being taken 
 to make no more prefTure with the knot 
 than is juft neceflary for preventing any 
 difcharge of blood. 
 
 We have defired, that in fecuring the di- 
 vided blood- veflels, both the artery and 
 veins ought to be tied; for if the veins are 
 not included in the ligature, a good deal of 
 blood may be difcharged from them, as they 
 are not furniihed with fo many valves as the 
 veins of other parts of the body. 
 
 The cord paffed at the upper part of the 
 procefs is to be left entirely loofe, and to 
 ferve only as a tourniquet for fecuring the 
 blood- veffels more readily in cafe the liga- 
 tures paffed upon them fhould accidentally 
 flip. There is in fadl no more neceffity 
 for allowing this ligature to remain tied, 
 than there is for leaving a tourniquet firmly 
 applied upon any of the extremities after 
 the operation of amputation ; and yet, in- 
 
 ftead 
 
Chap. IX. Of the Sarcocele, 527 
 
 ftead of one ligature of this kind, it has 
 been the pradlice with many, to apply 
 two, about half an inch diflant from one 
 another, by way of very great fecurity; 
 and thefe they leave firmly tied upon the 
 whole fubftance of the cord during the 
 cure of the fore*. 
 
 There is, however, no kind of neceffity 
 for this precaution, as all manner of rifk 
 may be entirely prevented by fecuring the 
 blood-vefTels in the manner we have here 
 direcfled. I have often done the operation 
 in this way, and I never faw any incon- 
 venience produced by it. By leaving the 
 ligature at the upper part of the wound 
 united, it may be made ufe of to comprefs 
 the cord in the event of the blood-veffels 
 burfting out again: But when the opera- 
 tion is properly done, this is an occurrence 
 that will be very feldom met with; and at 
 any rate, when it does unfortunately happen, 
 it may be always prevented from produ- 
 cing much mifchief by the ligature left for 
 
 that 
 
 *Even the late Mr Shavpe gives thefe directions. 
 Treatife on the Operation of Surgery ^ loth edit. p. ^^, 
 
528 Of tbs Sarcoccle, Chap. IX. 
 
 thac purpofe, and which may with Hifety 
 be removed at the fecond or third drefling 
 of the fore. 
 
 In making the ligature of the blood- 
 velFels at the extremity of the cord, if it is 
 necefTary to divide the procefs near to the 
 abdominal mufcles, as there is a poilibility, 
 of its retracting for a fmall fpace fo as to 
 get it within the ring, the ligature ought to 
 be cue of fuch a length as to admit of this; 
 a few inches of it, therefore, fhould be al- 
 ways left hanging over the fore, fo that it 
 may be pulled away at a proper time, in 
 the event of any retraclion taking place. 
 But we may here obferve, that this re- 
 traction never happens, when the cord 
 has not been too much feparated from 
 the iurrounding parts in endeavouring to 
 introduce the ligature below it. Indeed, 
 no farther feparation fhould be attempted 
 than merely to raife the cord fo far as to 
 get the point of the needle introduced be- 
 tween it and the bone. 
 
 In profecuting the removal of the teflicle, 
 the fcrotal artery is necelTariiy divided, and 
 
 it 
 
Chap. IX, Of the Ba-rcocele^ 529 
 
 it is fometimes of fach a fize as to difcliarge 
 a great deal of blood ; in which cafe i^ 
 fhould always, before going farther, be f^^ 
 cured by a ligature. 
 
 The parts being all removed, and the 
 different blood- yelTels all fecured as we 
 have here directed, a quantity of foft lint 
 fhould be gently laid into the bottom of 
 the fore; and a comprefs of linen being 
 applied over it, the whole fhould be fecured 
 either with the T-bandage, or with the fuf^ 
 penfory bag ufually employed in afFeclion? 
 of the fcrotum. The patient being now* 
 laid to reft, and an opiate adminiftered, th^ 
 fore ought not to be touched till a free 
 fuppuration takes place, which will gom-^ 
 monly be about the fifth or fixth day j and 
 then the dreflings fhould be removed, and 
 renewed from time to time, once every two 
 days or oftener, according as the quantity 
 of matter renders it neceffary. Now an4 
 then, after this operation, the patient eom-f 
 plains of much pain in the fore, and of ten^ 
 iion and unealinefs in the belly; in which 
 event, warmfomentationsfliould bg applie4 
 
 Vol. I. Ll %^ 
 
5 jo Of the Sarcocele: Chap-. IX, 
 
 to the abdomen, and the fore itfelf flioijld 
 be covered with an emolUent poultice, to be 
 repeated as often as may be necefTary. • 
 
 In defcribing the manner of performing 
 this operation, we fuppofe it to be done in 
 a cafe where the tefticle has not arrived at 
 any great bulk : In fuch a (ituation there 
 is never any good reafon for removing any 
 part of the fcrotum, as has been commonly 
 advifed*; for if the teguments are not 
 difeafed, or rendered very thin by being 
 much overftretched, they always recover 
 their tone very foon, and flaould not there- 
 fore be removed. 
 
 But, when the JGkin has become very 
 thin and inflamed, and efpecially if any of 
 it is adually in a ftate of ulceration, all 
 fuch parts of it ought to be removed along 
 with the tefticle. In fuch circumftanees 
 the beft method of doing it is this : In- 
 ftead of a longitudinal incifion along the 
 courfe of the tefticle, the firft incifion 
 ought to be carried in a ftraight line to the 
 
 under 
 
 * Mr Sharpe in fuch cafes advifes a portion of the fcro- 
 tum always to be removed, p. 55. he. cit. 
 
Chap. IX. Of the Bar mc eh, j^l 
 
 tinder extremity of the fpermatic cord; 
 from whence two femilunar incifions ought 
 to be continued to the under part of the 
 fcrotum, and fliould be made to include all 
 the parts of the £kin that are in any degree 
 difeafed. 
 
 In this fituation the remainder of the o- 
 peration ought to be exadlly the fame as we 
 have already defcribed : The fkin included 
 by the two femilunar cuts is not to be dif- 
 fedled off, but ought to be removed at once 
 with the difeafed teftiele. 
 
 CHAP. X. 
 Of the Bifedfes of the P e N I s. 
 
 SECTION L 
 
 Of the Fhymofiu 
 
 T 
 
 HE glans penis is naturally provided 
 
 with a covering termed the prapw 
 
 L 1 s imn; 
 
53^ O/'/^^ Phymofis. Chap. X, 
 
 thim; formed by an elongation and dou- 
 bling of the fkin. This in a healthy ftatc 
 is in general of fuch dimenfions as to pafs 
 eafily over the glans, but by difeafe it i» 
 frequently prevented from doing ib; and 
 when the prepuce has got forward, and 
 cannot be drawn back over the glans, the 
 difeafe thereby produced is termed a Phy- 
 moiis. 
 
 This complaint is induced by whatever 
 tends to fwell the glans, or to excite inflam- 
 mation and ftri<5lure in the preputium j 
 and in fbme people, the prepuce is fo tight, 
 as to render them liable to complaints of 
 this nature from very trifling caufes. An 
 exfudation of a whitifh, vifcid matter be- 
 tween the prepuce and glans is natural to 
 many; and the difeafe now under con- 
 lideration, is frequently the confequence 
 ©f want of cleanlinefs, by which this ma- 
 t-er is allowed to reft till it becomes acrid : 
 But the moft frequent caufe of it undoubt- 
 edly is the application of the venereal viru& 
 to thefe parts, by venereal intercourfe with, 
 difeafed women. 
 
Sea. I. Of the Phymoji's, 533 
 
 In flight afFecSlions of this kind, efpe- 
 cially when the diforder has not been of 
 long continuance, fomenting the parts fre- 
 quently in any warm emollient decodlion, 
 commonly gives relief; or what anfwers 
 perhaps better for fuch purpofes than any 
 decoction, is warm milkj this, together with 
 the ufe of emollient poultices with a view 
 to relax the conftridled preputium, will 
 often anfwer fo effecflually as to render any 
 other application unnecefTary. 
 
 At the fame time that fomentations and 
 poultices are applying in this manner ex- 
 ternally, part of the fomentation ought to 
 be injeded from time to time by means of ^ 
 a fyringe between the prepuce and glans^ 
 in order to wafh away any matter, either 
 of concealed chancres, or that may be pro- 
 duced merely by the inflammatory aflec- 
 tion of the part. 
 
 When the parts are much inflamed, 
 blood-letting often proves fervic cable : 
 When the fuperficial veins of the penis can. 
 be opened, any blood to be difcharged 
 be taken from one of them by the 
 L 1 3 lancet; 
 
534 OfthePhymofis. Chap. X. 
 
 lancet; but when they do not appear con- 
 fpicuous, difcharging it from the arm will 
 anfweras well as from any other part: Local 
 blood-letting by means of leeches would 
 be here particularly indicated ; but when 
 the diforder has originated from a venereal 
 taint, the bites produced by thefe animals 
 almoft conftantly terminate in troublefome 
 fores. Together with a difcharge of blood 
 proportioned to the ftrength of the patient, 
 gentle laxatives fliould be prefcribed, a low 
 diet, and abftinence from exercife. 
 
 When, however, it is found that even a 
 due perfeverance in thefe means has no in- 
 ilaence in removing the diforder, and efpe- 
 cially if chancres are confined under the 
 prepuce, which might injure the glans by" 
 the matte:r difcharged from them not get- 
 ting a proper vent, in that cafe it becomes 
 neceflary to remove the flrldlure by an in- 
 cifion carried along the whole courfe of the 
 preputium. 
 
 As the flsiin of the prepuce is exceedingly 
 Jax, it is almoft impofTible to cut it with 
 ^eatnefs and accuracy in the ordinary way, 
 
 either 
 
^^. / 
 
 W^/AAvy//,^ 
 
Sec^. I, Of the Thymofu, 
 
 jy 
 
 either 'by a fcalpel or blftoury; and when 
 done in this manner, the fkin yields fo 
 much before the inftrument, 'as always to 
 render it a very tedious and painful ope- 
 ration: Neither are the probe- fcilTars well 
 calculated for doing it properly, as the parts 
 are commonly fo thick as to be much brui- 
 fed by the blades of the inftrument. 
 
 Thefe inconveniences in this operation 
 being exceedingly obvious, many inven- 
 tions have been propofed for efFe<fling it 
 more eafily. in Plate XL is reprefented 
 an inftrument which I had made for this 
 purpofe feveral years ago, and it anfvvers 
 the intention very effeclually and v/ith 
 much eafe. 
 
 It conftfts of a director with a fmall 
 curve at its extremity, to which a fnarp- 
 pointed biftoury wuth a very narrow blade, 
 is fo exadlly adapted, as to have the cut- 
 ting part of it entirely concealed in the 
 groove of the director, which ought to be 
 about a quarter of an inch longer than the 
 Made of the knife. 
 
 Tlxs knife being infertedinto the direc- 
 L 1 4 tor 
 
jjfi Gfthe thymofis^ Chap.3C# 
 
 tor fo as to be concealed by it entirely, the 
 inflrument in this ftate is to be infinuated 
 between the prepuce and glans on one fide 
 of the penis, till the director is found by 
 the finger to have reached the upper end 
 of the preputium. The operator is now to 
 keep the director firm v/ith one hand, and 
 ■with the other is to pufli the knife for- 
 ward, fo as to make its point pafs through 
 the prepuce; and the director being with- 
 drawn, the operation is finiflied by draw- 
 ing the knife forward fo as to make it di-= 
 vide the prepuce through its whole length 
 along the fide of the penis. 
 
 In this manner the preputium is prefer- 
 ved in a tenfe (late while the divifion is 
 going on, by which means the operation is 
 ■very eafily accompliflied : And by making 
 the divifion on the fide of the penis, the 
 large veins of the part are avoided, which 
 they could fcarcely be if the operation was 
 done in the back part of it. 
 
 The prepuce being thus divided, the 
 parts below ought to be bathed with warm 
 ^ater fo as to wafh ofFeffedually any acrid 
 
 matter 
 
BeS:, I. Of the Pbymofis. 537 
 
 matter with which they may be covered ; 
 and this being done, the fore fhould be co- 
 vered with a bit of foft lint ; and a comprefs 
 of old linen being laid over it, the whole 
 may be very efFeclually retained by a fmall 
 linen bag adapted to the iize of the penis, 
 to be fecured by two flraps pinned to a 
 circular bandage made to furround the 
 body. This bag mud indeed be always 
 removed when the patient makes water; 
 but this is eafilv done ; and it retains the 
 dreffings, not only more effedlually, but 
 with more eafe to the patient, than is ever 
 done either with adhefive plafters or any 
 other form of bandage. 
 
 In the after- dreflings of the fore, care 
 fhould be taken to infert a piece of foft 
 lint between the divided prepuce and glans, 
 otherwife troublefome adhefions are apt to 
 opcur between them: 1 have met with feve- 
 ral inflances of this, which gave much di- 
 ilrefs to the patients, and which by a little 
 nicety and attention in drefling the fores 
 might very eafily have been prevented. 
 
 It is fcarcely necefTary to obferve, that 
 
 when 
 
53 S Of ike Phymojis^ Chap. X» 
 
 when ari)^ venereal infedlon fubfifts in the 
 conftltution, the fore produced by this ope- 
 ration will not readily heal, if the patient 
 be not put under a proper mercurial courfe. 
 In fuch circumftances therefore, if mercury 
 has not been previoufly adminiftered, it 
 ought always to be prefcribed immediately 
 on the operation taking place. 
 
 In fomc cafes of phymofis, the prepu- 
 tium is found to be fo very long, that in- 
 ftead of dividing it longitudinally, the 
 operation of circumcilion anfwers the pur- 
 pofe better; and it is very eaiily efFedted, 
 by taking away fuch a portion as may ap- 
 pear requiiite, of the whole circumference 
 of the prepuce. In fuch circumftances, 
 when the prepuce is naturally too long, the 
 removal of a quarter or half an inch of it 
 often frees the patient from what even be- 
 fore the approach of this difeafe he had 
 found to be inconvenient; and as the re- 
 moval of the extremity of the prepuce in 
 general allows the remainder to retra<fl ea- 
 fily, the operation is accordingly now and 
 then performed in this manner, 
 
 S E C T» 
 
Sedl. II. ()f the Faraphymofis 53^ 
 
 SECTION II. 
 Of the 'Paraphymofis. 
 
 13 Y the term Paraphymofis is meant a 
 morbid retraclion of the preputium, 
 producing ftriclure behind the glans penis. 
 This difeafe, like the former, is induced 
 mofh frequently by a venereal taint : but it 
 will arife from whatever tends to produce, 
 either a preternatural fulnefs in the glans, 
 or a con{lri(3:ion of the prepuce; and more 
 efpecially from fuch caufes as affed: a com- 
 plication of both. 
 
 In the incipient (late of this diforder, by 
 a little attention and dexterity, the prepuce 
 may be Ibmetimes brought over the glans, 
 by the furgeon pufhing the nut gently 
 back with both his thumbs, while his fin- 
 gers are at the fame time employed in mo- 
 ving the prepuce eaiily forward. In the 
 more advanced ftate of the difeafe, how-, 
 ever, no attempt of this kind ought to be 
 made, as it is in the commencement of it 
 only that it is ever known to fucceed; and 
 ^hen it does not prove ufeful, it is apt to 
 
 do 
 
54© Ofihe Paraphymofis, Chap. X 
 
 do harm, by inducing an increafed degree 
 of irritation in the parts to which the pref- 
 fure is applied. 
 
 As the paraphymofis feems evidently to 
 be more frequently induced by an enlarge- 
 ment of the glans than by any original af- 
 feclion of the prepuce, lo the llriclure in 
 the latter is not here fo efFedtually relieved 
 by warm fomentations, as it commonly is 
 in the phymofis, where the diforder is moft 
 frequently produced by an affedlion of the 
 prepuce itfelf. In the paraphymofis, in- 
 deed, I have often feen much harm done 
 by applications of this kind ; as they evi- 
 dently tend to produce an increafe in the 
 fwelling of the glans, by which the ftric- 
 ture in the prepuce is always proportion- 
 ally increafed. 
 
 Nothing in general anfwers fo well here 
 as the faturnine applications. Such fwell- 
 ings, indeed, will often fubfide by being 
 frequently immerfed in a cold folution of 
 faccharum faturni, when no other remedy 
 has any influence. But, when the penis is 
 evidently much fwelled and inflamed, to- 
 
 gethei: 
 
Se6l.II. OftheParaphymofis 54 1 
 
 gether with this application to the part, 
 the patient ought to be kept cool, gentle 
 laxatives fhould be prefcribed, and difchar- 
 ging blood from one of thefuperficial veins 
 of the penis is fometimes of ufe. 
 
 By a due continuation of thefe means, 
 and by keeping the patient on a low diet, 
 this diforder will mod frequently be remo- 
 Ted : But when, notwithflanding the ufe 
 of thefe remedies, the difeafe proceeds to 
 increafe, by the fwelling in the glans be- 
 coming more conliderable, and the flric- 
 ture of the prepuce increafing, an oedema-^ 
 tous fwelling begins to appear in the lat- 
 ter, which on fome occalions acquires a 
 conliderable degree of magnitude ; and un- 
 lefs relief be now obtained by a complete 
 removal of the ftridlure, mortification of 
 the glans itfelf is very apt to occur. 
 
 When, therefore, none of the remedies 
 •we have recommended prove effecflual in 
 preventing this ftage of the diforder, we 
 are now to attempt to remove the ftri(fl:ure 
 by an operation; and the eafieft method of 
 performing this, is, with the flioulder of a 
 
 lancet 
 
542 Oj the Faraphymofis. Chap.X. 
 
 lancet to make a deep fcarification on each 
 iide of the penis, dire3lly behind the glans ; 
 taking care to make each cut of about half 
 an inch in length, and of fuch a depth as 
 efFedlually to divide the prepuce juft at its 
 termination. 
 
 The parts ought now to be allowed to 
 bleed freely, as this circumftance of itfelf 
 in general affords immediate relief; and 
 as foon as the hemorrhagy flops, a pledgit 
 of any emollient ointment being appHed 
 to the fores, and a foft well-made poultice 
 being laid over the whole, if the fcarifica- 
 tions have been carried entirely through 
 the flriclure, nothing farther will in gene- 
 ral be neceffary than drefling the parts 
 daily with the fame ointment with which 
 they were at firft covered : but, if they have 
 not been made of a proper depth, it will 
 be afterwards neceffary to renew them ; 
 when care mufl be taken to do the bufi- 
 nefs effecftually. 
 
 In the phymofis, it was recommended 
 to put the patient under a mercurial courfe 
 whenever there is the lead reafon to fufpe(fl 
 
 that- 
 
SecEl.lI. OftheParaphymofu» 543 
 
 that any venereal taint fubfifts in the con- 
 flitution ; and the fame precaution, it ia 
 evident, mud be equally proper in cafes of 
 paraphymofis. 
 
 SECTION III. 
 Of Amputation of the Penis, &c, 
 
 nnHE penis, like other parts of the body, 
 is liable to diforders, which fome- 
 times renders it neceffary to remove the 
 parts affedled by amputation. 
 
 Thus we know, that on fome occafions 
 the penis is feizedwith mortification, and 
 it is frequently attacked with fores of the 
 cancerous kind: And when mortification 
 has been induced either by a neglecfted pa- 
 raphymofis or by any other caufe, it be- 
 comes neceffary to remove the difeafed 
 parts ; as is likewife the cafe when any 
 part of the penis is feized with a cancerous 
 fore, which, inftead of healing by the 
 means regularly employed for its removal, 
 proceeds to turn worfe. 
 
 We have elfewhere entered fully into the 
 4 con- 
 
544 Amputation of the Penis^ &c. Chap. ]^, 
 
 confideration both of cancerous diforders 
 and of mortification'^. To what was then 
 faid refpecling the treatment of thefe aiffec- 
 tions we mud now refer, and (hall at pre- 
 fent attend only to the operation of ampu- 
 tating the penis whenever it has become 
 fo difeafed as to render this necefTary. 
 
 A circular incifion ought to be firft 
 made through the found Ikin at the far- 
 theft extremity of the fore, and the fkin 
 fhould be then drawn back by an affiftant; 
 when the body of the penis fhould be cut 
 through by one ftroke of the fcalpei, care 
 being taken to remove every part that ap- 
 pears to be in any degree difeafed. 
 
 This being done, fuch arteries as bleed 
 freely fhould be carefully fearched for, 
 and ought by all means to be fecured by 
 ligature. In general, two, and fometimes 
 three branches, of an artery will be met 
 with ; and they fhould all be fecured in this 
 manner. But even after the principal ar- 
 teries have been tied, a confiderable ooz- 
 ing 
 
 * Vide Treatife on the Theory and Management of 
 ylgers^ &c. ^ 
 
Cliap.^X. Amputation of the Penis, 54^^ 
 
 ing of blood ufually occurs from the fur- 
 face of the fore, which the -fprinkhng with 
 ftarch or gum arabic in fine powder will 
 fometimes command ; but when this does 
 not anfwer, a fmall filver canula being in- 
 troduced into the urethra, and retained 
 there by a proper bandage, any farther 
 difcharge of blood may be very eafily Ilopt 
 by a flight comprefTion made with a nar- 
 row roller upon the remaining parts. A 
 very flight comprefhon anfwers the pur- 
 pofe, fuch a degree of it indeed as has no 
 influence in hurting the parts on which it 
 is made ; and as there is no neceflity for 
 the tube inferted into the urethra being of 
 a great lengthy it is eafiiy retained during 
 the whole cure without being produclive 
 of much inconvenience, 
 
 In Plate IX. fig. 4. is reprefented a tube 
 •which I have on different occafions ufed for 
 this purpofe. A. the tube itfelf; B. B. two 
 ligatures for connecf^ing it to a bandage 
 pafTed round the patient's body. 
 
 Heifter and fome other authors, being 
 afraid of the hemorrhagy produced by 
 amputation of the penis, advife it to bs 
 
 Vol, I. M m done 
 
546 Ampiit at 1071 of the Penis. Chap. X. 
 
 donel)y means of a ligature. A ligature 
 being applied with fafficienc firmnefs a 
 little above the difeafed parts, , they are 
 thereby made to fall off in the courfe of 
 iix or eight days ; but whenever a part 
 cah be removed by the fcalpel, it is done 
 •with much more eafe and certainty than 
 by ligature. 
 
 Others, again, have faid, that there is 
 little or no danger to be apprehended from 
 any difcharge of blood that can ever occur 
 here ; but this I know from experience is 
 far from being the cafe. In the courfe of 
 one feafon, I had occafion to perform this 
 operation three different times in the Royal 
 Infirmary here ; and in the firll I was per- 
 fuaded by a gentleman who had found it 
 in one cafe to fucceed, not to fecure the 
 arteries by ligatures, but to truft entirely 
 to compreflion. This was accordingly 
 done ; but unfortunately, in the courfe of 
 an hour or two after the operation, fuch a 
 profufe hemorrhagy fupervened as termi- 
 nated in the patient's death. 
 
 In the next that occurred I was refolved 
 to fecure every branch of an artery that 
 
 could 
 
Chap. X. Amp lit at ion of the Penis. 54^ 
 
 could be laid hold of. Three dlfFerent ar- 
 teries were accordingly tied, and no he" 
 morrhagy" enfued. In the third opera- 
 tion, two branches of an artery were fe- 
 cured ; but a plentiful oozing ftill conti- 
 nuing from the fore, the lilver tube above- 
 mentioned was introduced into the ure- 
 thra, and a flight compreflion being made 
 upon it, the h^morrhagy was thereby ef- 
 fedually ftopt. 
 
 When any arteries that appear have been 
 fecured in the manner direcled, the parts 
 ought to be covered with pieces of foft 
 lint fprinkled with ftarch or gum arable 
 in powder ; and a comprefs of linen, with 
 a hole in it large enough to pafs over the 
 canula in the urethra, being laid over the 
 whole, and the T-bandage being employ- 
 ed to retain it, all the drefhngs may in 
 this manner be effediially fecured. And 
 the after treatment of the fore fliould be fl- 
 milar to that of wounds in any other part- 
 In proceeding to this operation it ought 
 to be kept in view, that the prepuce is fre- 
 quently fo much enlarged and ulcerated, 
 as to give caufe to fufpecl the glans and. 
 M m 2 other 
 
54^ imputation of the Penis. Chap. }t. 
 
 other parts below to be much difeafed, 
 when in reaUty they are perfedlly found. 
 I once faw an inftance of this, where the 
 appearances previous to the operation were 
 fuch as gave no reafon ta doubt of the 
 glans being affedled ; and the prepuce with 
 part of the penis were accordingly taken 
 off, when it afterwards appeared that the 
 glans might have been faved, as the dif^ 
 eafe was found to be entirely confined to 
 the prepuce. 
 
 In every cafe, therefore, where there is 
 not an abfolute certainty of the glans be- 
 ing affecfled, all the difeafed prepuce fliould 
 be firft removed ; and the ftate of the parts 
 below being examined, if they are found 
 to be fo much affedted as to render ampu- 
 tation neceffary, this can be then done 
 with as much eafe as if they had been 
 taken off along with the prepuce ; and on 
 the contrary, if they are difcovered to be 
 found, both the furgeon and patient will 
 have much caufe to rejoice. 
 
 It fometimes happens, that the frenum 
 of the penis is fo fliort as to create a good 
 deal of uneaiinefs to the parts when in a 
 
 ftate 
 
Se6l. III. Amputation of the Penis, 540 
 
 (late of erection. But as there is no dan- 
 ger to be dreaded from a divifion of this 
 ligament, whenever it proves tronblefome 
 it may with great fafety be cut acrofs; and 
 it is very eafily done with a pair of probe - 
 pointed fcifTars ; After the frenum is fairly 
 divided, a bit of foft lint ought to be in- 
 ferted between the lips of the wound, other- 
 wife the parts newly feparated will be apt 
 to re-vmite immediately. 
 
 On fome occafions, the urethra in male 
 children is found to be incomplete, by ter- 
 minating before it reaches the extremity 
 of the yard. Now and then it does fo 
 without any external opening, and at other 
 times it terminates by a fmall orifice at 
 fome dillance from the end of the penis. 
 
 When no opening is difcovered out- 
 wardly, if the urine is found to flop at 
 any particular part, the introdudion of a 
 fmall trocar from the point of the yard 
 along the courfe that the urethra ought to 
 take, and carrying it forward till it meets 
 with the urine, will always afford imme- 
 diate relief: and bv the ufe of fmall bou- 
 gies the fides of the paffage may be ren- 
 M m 3 der- 
 
^^o Amputation of the Penis. Chap. X . 
 
 dered callous, and a clear opening be thus 
 preferved. But when any opening isdif-^ 
 covered, although it fhould not be pro- 
 perly placed, yet if it affords a temporary 
 pafTage to the urine, it is better to delay 
 the operation till the patient is fomewhat 
 advanced in life; and on an opening being 
 then made v/ith a trocar in the manner we 
 have mentioned, a piece of ticxible cathe- 
 ter may be introduced, not only for pre- 
 fer ving the paffage free and pervious, but 
 for carrying off the water till a cure is 
 obtained. In the earlier periods of child- 
 hood, the fmallnefs of parts through which 
 it ought to pafs, renders the flexible cathe- 
 ter altogether inadmilTible. 
 
 Independently of thefe afl'edions of the 
 penis which we have been jufl conlldering, 
 iiilulous openings frequently occur in the 
 •urethra, and they are alwaye produdlive of 
 much diftrefs. Thefe we (hall attend to 
 when we come to treat of the Fiftula in 
 Ano and Perinseo ; and the treatment of 
 Stones impaded in the Urethra, will fall 
 to be coniidered under the operation of 
 Lithotomy. 
 
EXPLANATION of the PLATES. 
 
 P L A T E L 
 
 {[Oppofite to page 22.] 
 
 Fig. I. A form of hook, commonly ter- 
 med a tenaculum, for the purpofe of pul- 
 ling out bleeding vefTels to be tied by liga- 
 tures. 
 
 Fig. 2. and 3. Two needles of a different 
 curve from thofe in ordinary ufe. The cur- 
 vatures being altogether on their fore-parts, 
 and the handles perfectly (Iraight, they are 
 thereby more eafily managed than the o- 
 thers, particularly in deep wounds. Fig. 5. 
 and 6. reprefent two needles of the ufual 
 .form ; but neither thefe nor the other two 
 have an edge on their concave parts. They 
 are made fomewhat round like a lancec, 
 both on their convex and concave iides ; 
 which adds to their flrength, and makes 
 M m 4 ' them 
 
£^2 E2ip!dnatio7i cf the Plates. 
 
 them enter with more eafe than the others. 
 I have lon^ made ufe of thofe needles, and 
 whoever employs them will find them pre- 
 ferable in every refpec^ to the others. 
 
 Figs. 4. and 7. Two ftraight needles for 
 futures of the inteftines and other delicate 
 membranous parts. 
 
 All thefe needles are reprefented of the 
 full fize. 
 
 A number of inftruments have been 
 contrived for holding the needles when 
 they are to be employed in deep wounds. 
 The Port- aiguille reprefented in Plate II. 
 will anfwer this purpofe as well as any 
 other ; but inftruments of this kind can- 
 not be often needed. 
 
 Plate II. 
 
 rOppofite to page 32.] 
 
 Fig. I. A Porte-aiguille mentioned in p.3 2. 
 
 A. A. The handles of the inftrument. 
 
 B. A groove for receiving the pins ufed 
 \ii the twifted future. 
 
 ^This inftrument is commonly made with 
 n ilider for bxing the handles after the pins 
 
 are 
 
Explanation of the Plates, ce% 
 
 are inferted into the groove ; but as this al- 
 ways proves troublefome to the operator, 
 and is not in any degree neceflary, it is here 
 purpofely omitted. 
 
 Fig. 2.3. and 4. are different fizes of pins 
 ufed in the twifted future defcribed p. 29. 
 
 And fig. 5. is a flat needle fometim^s 
 found ufeful in flitching blood-velTels chat 
 lie between contiguous bones. 
 
 All the inftruments in this plate are r€» 
 prefented of their full fize. 
 
 Plate III. 
 
 [Oppofite to page 42.3 
 
 Fig. I. A fcrew tourniquet defcribed^ 
 p. 43. Every pare of the inftrument is 
 here reprefented of the full fize : It may 
 be made either of brafs or fleel ; and the 
 ftrap connected with it ought to be of very 
 firm materials, at lead an inch broad, and 
 of a length fufficient to pafs fully round 
 the largeft circumference of any of the ex- 
 tremities. 
 
 Fig. 2. A fprlng phleme defcribed, p. 86> 
 
 89, 
 
554 Explanation of the Plata, 
 
 89. This inflrument is alfo reprefented of 
 the full fize. 
 
 Plate IV. 
 
 [Oppohtc to page 88.2 
 
 Fig. I. and 2. Two fcalpels of the bed 
 form, either for the anatomifh or furgeon. 
 Fig. I. is of a fize large enough for any 
 operation ; and fig. 2. is of a very ufeful 
 fize for operations about the eyes, mouth, 
 and other parts where a larger inftrument 
 proves inconvenient. 
 
 Fig. 3. and. 4. The beft form of lancet 
 for the operationof blood-letting, defcribed 
 p. 90. fig. 3. is of a full fize for any pur- 
 pofe of this kind ; and fig. 4. is for the 
 fmall veins of infants. 
 
 Fig. 5. reprefents the broad- fhouldered 
 lancet in ordinary ufe ; but which, from 
 its figure, is evidently ill-fuited for the nice 
 operation of venxfeclion. 
 
 Plate V. 
 
 [Oppoute to pagt 172.3 
 
 Pig. I. Afcarificator with fixteen lancets 
 
'Explanation of the Flates, ^^^ 
 
 Ay a cubical brafs box, in which the blades 
 of the lancets firmly fixed on an axis are 
 included. B^ a liver for bending a fpring 
 with which the axis and its lancets are 
 connected. C, a button or head of a fcrew- 
 nail connected with a catch for fecuring 
 the fpring in a bent ftate : On the fpring 
 being bent by means of the lever -5, and 
 the flat part of the inftrument D D being 
 placed upon the part to be fcarified, the 
 button C is then to be prefTed upon till the 
 fpring is unbent, which forces the lancets 
 into the parts they are placed upon, to the 
 depth at which they have been previoufly 
 fet ; and the flat covering of the box D D 
 being moveable, ferves to regulate the 
 length of the lancets which pafs thro' it. 
 
 Fig. 3. Acupping-glafs with a mouth of 
 an oval form ; and fig. 4, reprefents one of 
 the ordinary round kind. 
 
 Fig. 2. A flrong curved needle, with a 
 round though fomewhat Iharp point. This 
 inftrument anfwers the purpofe better than 
 any yet contrived, for introducing ligatures 
 below the artery, in the operation for the 
 
 aneurifm ; 
 
^^6 Explanation of the Plates, 
 
 aneurifm ; and below the fpe?matic cord, 
 in the operation of caflration. 
 
 All the inftruments of this plate are re-^ 
 prefented of a proper fize for ufe. 
 
 Plate VI. 
 
 [[OppoGte to page 2S9.] 
 
 Fig. 1.2. and 3. reprefent different parts 
 of a machine for injed^ing tobacco-fmojce 
 by the anus. 
 
 Fig. I. A brafs box for containing the 
 burning tobacco. The mark ^ is a bot- 
 tom or divifion in the infide of the box, 
 perforated with fmall holes to admit the 
 paffage of the fmoke to the extremity of tRe 
 boxZ» ; which, by a male fcrew, is adapted 
 to a brafs tube, fig. 3. at /), which is 
 again fitted to an elaftic leather pipe Ey 
 terminated by a common glyfter-pipe F» 
 The pipe E is made of waxed leather, pro- 
 tedled by brafs wire rolled fpirally round 
 it from one extremity to the other. 
 
 Fig. 2. reprefents the covering of the 
 box, fig. I. to which it mull be exadly 
 fitted. (?, a divifion of thin brafs, per- 
 forated 
 
Explanation of the Plates, ^^'f 
 
 forated with a number of fmall holes for 
 admitting the pafTage of the air from a 
 pair of bellows fitted to the opening ff. 
 
 Fig. 3. The inftrument completely fitted 
 up on a fmall fcale. /a pair of double 
 bellows, whofe tube K is fitted by a fcrew 
 to an opening in the cover of the box L^ 
 which again is terminated by the brafs 
 tube M, the leather pipe iV, and the ordi- 
 nary glyfter-pipe 0. 
 
 The box L being filled with burning 
 tobacco, and the glyfter-pipe O being in- 
 ferted into the anuj, by working the bel- 
 lows /, any neceflary quantity of fmoke 
 may be very quickly thrown up. 
 
 It is fcarcely neceffary to obferve, that 
 all the parts of this machine ought to be 
 exadly fitted to one another, with a view 
 to prevent efFedually the efcape of fmoke 
 at any of the joints. 
 
 Bellows of the ordinary fize anfwer very 
 well for this purpofe ; and are preferable to 
 ihofe of a fmaller fize, as being better calcu- 
 lated for injedling the fmoke quickly. The 
 brafs- box for the tobacco fliould be about 
 
558 Explanation of the Plates. 
 
 an inch and half 'in diameter, by three 
 inches in length from the brim to the bot- 
 tom ; the brafs tube connedled with the 
 box fhould be fix inches in length, by a 
 quarter of an inch in diameter. The lea- 
 ther pipe ought to be of nearly the fame 
 diameter with the tube, and about two 
 feet and a half in length. When of this 
 length, it is eafier managed than when 
 fhorter ; and it ferves more effedually to 
 cool the fmoke before it is thrown into the 
 bowels. 
 
 The glyfter-pipe at the end of the lea- 
 ther pipe ought to be fomewhat larger and 
 wider than thofe in ordinary ufe. 
 
 Plate VIL 
 
 [^Oppofite to page 290.] 
 
 Fig. I. Another inftrument for the pur- 
 pofe of inje(5ling tobacco- fmoke, originally 
 invented by the celebrated profeffor Gau- 
 bius. The principal difference between 
 this and the inftrument reprefented in 
 Plate VI. is, that in this the tobacco-box 
 ^, is fitted to the air-hole of the bellows ; 
 
 fo 
 
Explanation of ihe Plates, 5^9 
 
 fo that in working the bellows, the air 
 with which they are fupplied entering ia 
 at the openings B^ the fmoke of the burn- 
 ing tobacco mud accordingly pafs through 
 them ; and from the bellows it is thrown 
 into the other parts of the inftrument, and 
 in that manner is tranfmitted to the in- 
 teftines. 
 
 The other inflrument reprefented in 
 Plate VI. is wrought with more eafe than 
 the one here delineated. 
 
 Fig. 2. A crooked biftoury, with a blunt 
 or probe point. The curve here reprefented 
 is much lefs than is ufually given to this 
 inftrument, and the blade is alfo much 
 narrower : It ought, indeed, to be altoge- 
 ther ftraight, excepting a vei'y flight cur- 
 vature towards its point. 
 
 This biftoury is well calculated for di- 
 viding the ftriclure in cafes of hernia ; for 
 opening finufes in every fituation ; and 
 particularly for dividing the re(f\um in the 
 operation of the fiftula in ano. 
 
 Fig. 3. A bandage for compreffing the 
 
 temporal artery, either after the operation of 
 
 3 Ar- 
 
t66 Explanation of the Plates^ 
 
 Arteriotomy, or in accidental divifions of 
 that artery. It is made of well tempered 
 fpring-fleel, covered with foft leather, and 
 of the fame ftrength as is ufed for the trufs 
 of a hernia. The wound being drefTed, 
 and a fmall comprefs of linen being applied 
 over it, the limbs of the inftrument are to 
 be opened, and applied over the back-part 
 of the head, fo that their extremities B D 
 may reft upon the temples, and one of them 
 be made to reft exadly upon a comprefa 
 covering the wound. If the inftrument is 
 made of proper metal, and of fufficient 
 ftrength, it will remain exadlly upon the 
 part on which it is firft placed without any 
 afliftance; but, to prevent its being rubbed 
 off by accident, it is here furnifhed with a 
 buckle and ftrap ACy by which it may be 
 firmly fixed by drawing them tight upon 
 the fore- head. 
 
 This inftrument fhould be about threef 
 quarters of an inch broad; and from twelve 
 to fourteen inches in length will anfwer for 
 the dimenfions of any head. 
 
 I once had a fcrew with a button adapt- 
 
Explanation of the Plate s» 561 
 
 ed to this bandage, the button being made 
 to prefs upon the divided artery ; but the 
 comprefs of linen here recommended, an- 
 fwers the purpofe better, and is eafier to the 
 patient: Bandages made of Unen or of other 
 materials of a yielding nature, do not an- 
 fwer fo well as thofe of fpring-fleel, which 
 always remain with more certainty on the 
 Ipot they are firft placed upon. 
 
 Plate. VIII. 
 
 £Oppofite to page 309.3 
 
 Fig. I. A fpring trufs for an inguinal 
 or femoral hernia of the right- fide. A^ the 
 bolder or pad for preiUng upon the open- 
 ing at which the parts have been accuf- 
 tomed to protrude. B^ a ftrap with holes 
 in it for fixing upon the knobs on the back 
 part of the pad. C, a ftrap hanging down, 
 from the back-part of the bandage, to be 
 palTed between the legs of the patient, and 
 to be alfo fixed upon the knobs of the pad 
 by the holes in its extremity. 
 
 This ftrap is intended to fix the ban- 
 dage firmly in its fituation; but if the 
 
 Vol. I. N n bandage 
 
562 Explanation of the Plates, 
 
 bandage is properly fitted to the parts, and 
 if the ileel-fpring of which it is compofed 
 is fufficiently elaftic, there is no neceflity 
 for the intervention of this flrap, which 
 always frets and galls the parts upon which 
 it is made to pafs. 
 
 Fig. 2. reprefents a bandage of this kind 
 for the left-fide with no back-ftrap. 
 
 Fig. 4. reprefents a double bandage af 
 the fame kind for a hernia on each fide, 
 with two back-flraps conneded with it. 
 
 The fleel of which thefe bandages are 
 made fhould be covered with thin fofr lea- 
 ther, properly fluffed with wool or flannel, 
 in order to prevent the parts from fret- 
 ting by the preflbre neceffarily produced 
 upon them. The pads ought to be broader 
 than they are generally made, with a pro- 
 minence or flight elevation in the middle, 
 while their fides are made perfe<5lly flat. 
 Of this conflru(flion they apply with much 
 more exaclnefs, and fit more firmly on the 
 parts than when altogether round as they 
 are commonly made, without any flatnefs^ 
 on their fides. 
 
Kxplanation of the Plates, ^6^ 
 
 Fig. 3. reprefents a bandage for umbi- 
 lical ruptures. ^, a fteel fpring to be ap- 
 plied upon the umbilicus after the hernia 
 has been reduced, and to be retained in 
 that fituation by the bandaged; which, 
 by means of the ftrap CCC and the buckles 
 DDD, may be kept at any degree of tight- 
 nefs. EE, two (traps for pafling over the 
 patient's flioulders; and Fa. ftrap for paf- 
 ing between the legs, the whole to be 
 fixed upon knobs on the back part of the 
 bandage oppofite to the fpring ^. By 
 means of thefe buckles and ftraps the ban- 
 dage may be preferved very firmly in its 
 fituation. 
 
 The belt B fiiould be five or fix inches 
 broad, and the fteel fpring A fliould be of 
 a fize proportioned to the opening it is 
 intended to prefs upon. All the parts of 
 the bandage fliould be made of foft lea- 
 ther, lined with flannel or cotton *. 
 
 N n 2 Plate 
 
 * The fpring here reprefented is taken from a figure 
 reprefented by the late Dr Monro in his treatife on that 
 fubjeft. See his Works in 4to. 
 
564 Explanation of the Plates^ 
 
 Plate. IX. 
 
 [Oppofite to page 380. J 
 
 Fig. T. A peiTary for the prevention of 
 herniae in the vagina. This peiTary con- 
 fifls of a conical tube of ivory, filver, or 
 gold, with a cord at its extremity, for the 
 purpofe of withdrawing it when necefTary. 
 The protruded parts being reduced, and 
 this cone being rubbed over with oil, is to 
 be introduced into the vagina, by which 
 any farther defcents may in general be 
 prevented. 
 
 PefTaries for this purpofe have been 
 formed of fpring-fteelj but the ruft which 
 inftruments of that metal are apt to con- 
 tradl renders them very unfit for fuch 
 ufes. 
 
 Fig. 2. A hook defcribed p. 376, for en- 
 larging the opening in the foramen ovale 
 in cafes of hernia of that part. This hook 
 was originally propofed by Mr Arnaud, a 
 French author, for dilating the pafFage at 
 which the parts protrude in cafes of crural 
 hernia. 
 
Explanation of the Plates, 565 
 
 Fig. 3. A diredlor open at the extre- 
 mity, defcribed p. 324, for the purpofe of 
 laying open the fac in the operation of the 
 bubonocele. ^ 
 
 Fig. 4. A filver canula for introducing 
 into the urethra after the operation of 
 amputating the penis. The firings with 
 which it is furnifhed are intended to fix it 
 to a circular bandage which ought to pals 
 round the patient's body. 
 
 P L AT E X. 
 
 [Oppofite to page 420.] 
 
 Fig. I. A trocar of a proper fize for eva- 
 cuating the contents of an encyfled hydro- 
 cele. By the flatnefs of its form, and its 
 point being of the lancet kind, this inftru- 
 ment penetrates the cyft wich great eafej 
 and can thereby be ufed with more fafety 
 than the ordinary form of this inflru- 
 ment. 
 
 The point of the perforator is commonly 
 made much longer than is neceflary. It 
 ought not to pafs more than the fifth or 
 lixth pkrt of an inch from the extremity 
 
 of 
 
^66 Explanation of the Plates, 
 
 of the canula; of this length it anfwers 
 equally well as when the point is longer; 
 and it is not fo apt to wound the teftis on 
 being introduced into the cavity of the 
 tunica vaginalis. 
 
 Fig. 2. A trocar, the invention of Mr 
 Andre. Fig. 3. The canula of this inftru- 
 msnt, formed of two hollow plates of ela- 
 flic fteel, firmly united together at their 
 larger extremities by two fcrew-nails. The 
 tube formed by thefe two hollow plates is 
 of fuch a fize as to allow the perforator? 
 fig. 4. to be pufhed into it with very little 
 force; and the elafticity of the plates, 
 which admits of their yielding to this 
 pafTage of the perforator, enables them to 
 return inftantly to form the fame fize of 
 tube, as foon as the large extremity of the 
 inftrument A has fairly pafTed the extre- 
 mity of the plates. 
 
 The point of the perforator with a fmall 
 portion of the extremity of the tube being 
 pullied into the vaginal coat, the perforator 
 is to be then withdrawn, which when the 
 
 inflru- 
 
Eocplanation of the Plates, ^6j 
 
 Inflrument is properly made may be done 
 without much force. 
 
 The advantage which this inftrument is 
 fuppofed to have over any trocar of a dif- 
 ferent form, is, that the point of the perfo- 
 rator making a larger opening than is juft 
 neceffary for the pafTage of the canula, the 
 latter is thereby made to enter with more 
 eafe than it does in the ufual form of the 
 inflrument. 
 
 But although this invention of Mr An- 
 dre's is neat and ingenious, it does not 
 appear to be very neceffary; for, when 
 the other form of inflrument is well fi- 
 nifhed, and the filver at the extremity of 
 the canula is made very thin and properly 
 fitted to the perforator, it enters with a 
 great deal of 6afe. The canula of Mr 
 Andre's inflrument has this difadvantage 
 too, that being made of fiiie polifhed fleel, 
 it is almofl impofTible to render it fo dry 
 after every time it is ufed, as to prevent it 
 from fuffering with rufl, at the part where 
 the two plates are fixed together by the 
 fcrew-nails. 
 
 4 Plate 
 
568 Explanation of the Plates^ 
 
 Plate. XL 
 
 [Oppofite to page 535.] 
 
 Fig. I. and 2. Different parts of an in- 
 flrument defcribed p 535 for performing 
 the operation of phymofis. 
 
 Fig. 3. The two parts of the inflrument 
 conneded and ready for ufe. 
 
 Fig. 4. A large impoftume lancet. 
 
 END OF VOL. I. 
 
 Directions to the Book-Binder. 
 Plate I. to face - page 22 
 
 n. - ■ - 32^ 
 
 m. - » 42 
 
 IV. - - - 88 
 
 V. - - 172 
 
 VI. - - 289 
 
 VU. - p 290 
 
 vni. - . 309 
 
 IX. - - 380 
 
 420 
 XI. . - 53^ 
 
 ■ .< ■■■ ' - 
 
 Printed bt MACFAR<ioaAR and Elliot, 
 
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